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 A

Explanation

A. Placing a pillow under the affected limb helps elevate the extremity, which can reduce swelling and promote circulation, enhancing recovery.

B. Applying cool compresses every 6 hours is not typically recommended postoperatively, as frequent, direct cooling could impede blood flow to the surgical area.

C. Promoting bed rest for 5-7 days is not advised; early mobility is encouraged to prevent complications such as deep vein thrombosis and improve joint function.

D. Encouraging increased fluid intake is important for general recovery, but it does not specifically address postoperative care for a knee replacement.

A. Encourage the client to sit up as much as possible. B. Elevate the stump on a pillow. C. Elevate the foot of the bed. D. Have the client lie prone several times per day.

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.

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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?

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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?