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. Because a score of 6 indicates the client is likely unresponsive or has very limited responses to stimuli, they cannot perform activities of daily living or protect their own airway. They require comprehensive, total nursing care.

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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Free Nursing Study Resources

Correct Answer is ["B","D"]

Explanation

A. A turning schedule every 4 hours is insufficient; repositioning should ideally be done every 2 hours to prevent pressure injuries.

B. Reducing skin exposure to moisture helps maintain skin integrity, especially in areas prone to breakdown due to moisture accumulation.

C. Powder is not recommended as it can lead to skin irritation and potential breakdown.

D. Elevating heels with pillows relieves pressure on areas that are susceptible to pressure injuries in immobilized clients.

E. Massaging erythematous bony prominences can damage capillaries and increase the risk of pressure injury formation.

A. Maintain the client on fluid restriction B. Educate the client that hematuria is expected following the procedure C. Notify the provider immediately if mucus is present in the urine D. Apply skin barrier to the stoma site E. Monitor hourly urine output

Correct Answer is ["B","D","E"]

Explanation

A. Fluid restriction is generally not indicated; maintaining hydration is important to ensure adequate urine output.

B. Hematuria is expected postoperatively due to surgical manipulation and should be explained to the client.

C. Mucus in the urine is common with an ileal conduit since the conduit is created using a portion of the intestine, which naturally produces mucus.

D. Applying a skin barrier protects the skin around the stoma site from irritation and breakdown.

E. Monitoring hourly urine output helps assess kidney function and the patency of the conduit.

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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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