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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Rationale:

A. Sitting up for prolonged periods can lead to hip contractures and should be limited.

B. Elevating the stump on a pillow is discouraged after the first 24-48 hours post-op, as it can lead to contracture formation.

C. Elevating the foot of the bed is not recommended as it may increase the risk of contractures and does not promote stump shaping.

D. Lying prone several times per day helps prevent hip flexion contractures, a common complication after an above-the-knee amputation.

A. Urge incontinence B. Weight gain C. Rectal distention D. Dribbling of urine

Correct Answer is D

Explanation

A. Urge incontinence may occur but is not necessarily an indicator for immediate catheterization in a paraplegic patient, as they may lack bladder control.

B. Weight gain is unrelated to the need for catheterization and may indicate other issues like fluid retention.

C. Rectal distention relates to bowel function, not bladder function, and does not indicate the need for catheterization.

D. Dribbling of urine can suggest bladder overfilling and is an indication that the bladder needs emptying through catheterization to prevent urinary retention complications.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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