The nurse is caring for a client with brain trauma who is in a coma. The client's Glascow Coma Scale is 6. Which response would the nurse expect the client to have?

Able to localize pain

Is verbally responsive, but confused

Moves arms as directed

Opens eye to deep pain only

Answer and Explanation

The Correct Answer is D

A. Able to localize pain: A score of 6 is too low for a client to localize pain, which would require higher motor function.

B. Is verbally responsive, but confused: Verbal responsiveness would require a higher score, as a GCS of 6 indicates severe impairment.

C. Moves arms as directed: Following commands is consistent with a higher GCS score.

D. Opens eyes to deep pain only: This response aligns with the minimal responsiveness expected for a GCS score of 6.

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Correct Answer is B

Explanation

A. Congenital valve abnormalities: Although congenital heart defects can cause aortic stenosis, rheumatic fever is a more common cause in adults.

B. Rheumatic fever: Rheumatic fever is the most common cause of aortic stenosis in adults, as it can lead to scarring and narrowing of the aortic valve.

C. Autoimmune deficiency syndrome: This is not associated with aortic stenosis.

D. Degenerative calcification of valve: This is a common cause of aortic stenosis in older adults, but it is generally less common than rheumatic fever as the primary cause in a younger or middle-aged population.

A. 3% hypertonic saline B. Normal saline solution C. Dextrose 5% in water D. Lactated Ringers

Correct Answer is A

Explanation

A. 3% hypertonic saline: In SIADH, the body holds onto too much water, leading to dilutional hyponatremia. Hypertonic saline helps to slowly raise the sodium level and correct the dilution.

B. Normal saline solution: Normal saline (0.9%) would not be effective for SIADH as it is isotonic and would not correct the sodium imbalance.

C. Dextrose 5% in water: This would not be appropriate, as it contains free water and could exacerbate hyponatremia in a client with SIADH.

D. Lactated Ringers: This is an isotonic solution and would not effectively address the dilutional hyponatremia caused by SIADH.

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The nurse is caring for a client with brain trauma who is in a coma. The client's Glascow Coma Scale is 6. Which response would the nurse expect the client to have?

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The nurse is caring for a client with brain trauma who is in a coma. The client's Glascow Coma Scale is 6. Which response would the nurse expect the client to have?