Á nurse is assessing a client who has a score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score?
The client is alert and oriented.
Indicates stable neurologic status
The client needs total nursing care.
The client is in a deep coma.
The Correct Answer is C
A. A score of 6 indicates a severe impairment in consciousness, not alertness and orientation.
B. A score of 6 does not indicate a stable neurologic status but rather severe brain injury or impairment.
C. Clients with a GCS of 6 typically need total care, as they are unable to perform self-care activities and may be unable to respond to commands.
D. While a GCS of 3 indicates deep coma, a score of 6 reflects severe impairment, though not necessarily a deep coma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E","F"]
Explanation
A. Heart rate: The increased heart rate (108/min) may indicate a developing complication such as hypovolemia or pain. This requires monitoring as it could signal deteriorating status.
B. Oxygen saturation: The SpO₂ level is stable at 96%, which is within an acceptable range and does not indicate an immediate concern.
C. Edema: The increase in sacral and iliac region edema (2+) from day 1 to day 2 suggests worsening swelling and possible fluid accumulation, which could be affecting blood flow and leading to circulatory issues.
D. Temperature: The temperature remains within a normal range, so it does not require immediate intervention.
E. Urine color: Dark, reddish-brown urine suggests possible bleeding or rhabdomyolysis, both of which require immediate follow-up to prevent further complications and assess kidney function.
F. Pedal pulses: The change to 1+ pedal pulses bilaterally and the delayed capillary refill time (6 seconds) indicate reduced perfusion to the lower extremities, which may suggest compromised circulation or increased edema affecting blood flow.
Correct Answer is B
Explanation
A. Lifelong heparin usage is not the standard treatment for DIC, as treatment focuses on addressing the underlying cause and managing symptoms.
B. DIC is a condition characterized by abnormal, excessive coagulation involving the use of clotting factors, particularly fibrinogen, leading to widespread clotting and bleeding.
C. DIC is not a genetic disorder or directly related to vitamin K deficiency.
D. DIC typically leads to a decreased platelet count due to consumption of platelets in widespread clotting, not an elevated count.
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