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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 B

Explanation

A. While monitoring erythrocytes, hemoglobin, and hematocrit is important in clients with ESRD due to the risk of anemia associated with kidney dysfunction, it is not the primary focus of monitoring for ESRD.

B. Clients with ESRD often experience electrolyte imbalances, including hyperkalemia (high potassium), hypocalcemia (low calcium), and hyperphosphatemia (high phosphorus). Monitoring these electrolyte levels is crucial to prevent complications such as cardiac arrhythmias, bone
disease, and soft tissue calcifications.

C. While blood pressure, heart rate, and temperature are essential vital signs to monitor in all clients, they are not specific laboratory tests for monitoring ESRD. However, blood pressure monitoring is particularly important in ESRD due to the increased risk of hypertension and its associated complications.

D. Monitoring leukocytes, neutrophils, and thyroxine levels is not typically a primary concern in clients with ESRD. Leukocyte and neutrophil levels may be monitored to assess for signs of infection, but they are not specific to ESRD. Thyroxine levels are typically monitored in clients with thyroid disorders, not ESRD.

A. Avoid stimulation of the breasts and wear a tight bra. B. Express a small amount of breast milk by hand. C. Place warm packs on both breasts. D. Take a prescribed analgesic and expose breasts to air. E. None F. None

Correct Answer is A

Explanation

A. Avoid stimulation of the breasts and wear a tight bra: This is the most appropriate recommendation for a bottle-feeding postpartum client with breast engorgement. Minimizing breast stimulation and wearing a supportive, tight-fitting bra can help reduce milk production and alleviate discomfort.

B. Express a small amount of breast milk by hand: This action may provide temporary relief but can stimulate further milk production, which is not advisable for a client who is bottle-feeding and attempting to suppress lactation.

C. Place warm packs on both breasts: Warmth can promote milk flow and is typically recommended for breastfeeding mothers. For a bottle-feeding client, cold compresses are more appropriate to reduce engorgement.

D. Take a prescribed analgesic and expose breasts to air: While analgesics can help manage discomfort, exposing the breasts to air has no therapeutic benefit for engorgement and may increase discomfort. This is not the best overall recommendation.

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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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Exhibits

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