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Exhibits

Which may have caused the change in the Glasgow Coma Scale score between 2000 and 2400? Select all that apply.

The client may be developing sepsis.

The client may be dehydrated.

The client may have increasing symptoms of head injury.

The client may have been sleeping.

The client may be improving clinically.

The client may require more morphine

The client may be experiencing sedative effects of morphine.

Answer and Explanation

Correct Answer : C,D,G

A. The client may be developing sepsis.

Sepsis typically presents with symptoms such as fever, increased heart rate, increased respiratory rate, and altered blood pressure. There is no indication of these signs in the provided data,
making sepsis an unlikely cause for the change in the Glasgow Coma Scale (GCS) score.

B. The client may be dehydrated.

Dehydration can affect cognitive function, but there is no evidence suggesting dehydration in this scenario (e.g., normal heart rate, blood pressure, and no noted intake/output imbalance).
C. The client may have increasing symptoms of head injury.

A decrease in GCS score can indicate worsening head injury symptoms, such as increased intracranial pressure or bleeding.
D. The client may have been sleeping.

Sleeping can temporarily affect the GCS score, particularly the eye-opening component.

E. The client may be improving clinically.

Improvement clinically would likely result in a stable or improved GCS score, not a decrease.

F. The client may require more morphine.

Needing more morphine would typically be due to increased pain, but this should not directly affect the GCS score unless severe pain is causing altered consciousness, which is not indicated here.
G. The client may be experiencing sedative effects of morphine.

Morphine, especially given intravenously, can cause sedation, which could lower the GCS score.

H. The client may need food.

Needing food would not typically cause an immediate change in GCS score unless associated with severe hypoglycemia, which is not indicated by the provided data.

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

Explanation

A. Blood culture is essential to identify any potential infection that the patient may have, which is a common complication after trauma.
B . Prothrombin time is crucial for assessing the blood's clotting ability, especially since the patient has a suspected fracture and could be at risk of bleeding.
C . Hemoglobin and hematocrit are fundamental tests to evaluate for anemia or blood loss, which is particularly relevant given the patient's fall and the possibility of internal injuries. D . Type and screen is necessary in case the patient requires a blood transfusion due to the injuries sustained from the fall.
E . Albumin is not typically a priority in acute trauma settings and would not necessarily be expected as an immediate test.
F . Lipid panel is not relevant in the acute management of trauma and is not typically ordered in the emergency setting

A. Core strengthening. B. Aerobic exercise. C. Weight-bearing exercise. D. Muscle stretching and toning.

Correct Answer is C

Explanation

A. Core strengthening. While important for overall health, core strengthening is not as directly effective for osteoporosis prevention as weight-bearing exercise.
B. Aerobic exercise. Aerobic exercise is beneficial for cardiovascular health but does not have the same bone-strengthening effect as weight-bearing exercise.
C. Weight-bearing exercise. Weight-bearing exercises, such as walking, jogging, and strength training, are essential for maintaining bone density and preventing osteoporosis.
D. Muscle stretching and toning. Stretching and toning are important for flexibility and muscle health but do not significantly impact bone density compared to weight-bearing exercises.

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Exhibits Which may have caused the change in the Glasgow Coma Scale score between 2000 and 2400? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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Exhibits

Which may have caused the change in the Glasgow Coma Scale score between 2000 and 2400? Select all that apply.