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A client is admitted with posttraumatic brain injury and multiple fractures. The client's eyes remain closed, and there is no evidence of verbalization or movement when the nurse changes the client's position. What score on the Glasgow Coma Scale (GCS) should the nurse document?
- A. 3
- B. 6
- C. 9
- D. 12
Correct Answer: A
Rationale: GCS assesses eye opening (1-4), verbal (1-5), and motor (1-6). No response (eyes closed, no verbalization, no movement) scores 1+1+1=3 (A). Higher scores (B, C, D) require responses. A is correct. Rationale: A score of 3 is the lowest GCS, indicating deep coma, critical for documenting severe brain injury and guiding urgent care, per trauma assessment standards.
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Which of the following statement best describe a living will?
- A. A legal document that states what the client wants to happen should he become incapacitated
- B. A legal document assigning a proxy to make a decision
- C. A legal document that prohibits CPR
- D. A legal document that assigns properties to relatives
Correct Answer: A
Rationale: A living will is a legal document stating care wishes if incapacitated (A), per advance directive definitions e.g., ventilation preferences. Proxy assignment (B) is a power of attorney, CPR prohibition (C) is DNR, property (D) a will. A best captures its intent, making it correct.
The nurse is assessing the client for abdominal distention, which of the following technique should be performed by the nurse?
- A. Inspection alone is sufficient
- B. Inspection and Palpation
- C. Inspection and Percussion
- D. Inspection, Palpation and Percussion
Correct Answer: C
Rationale: Abdominal distention needs inspection (e.g., bloating) and percussion (e.g., tympany for gas) unlike inspection alone or palpation (tenderness). Nurses use e.g., tap for cause, per assessment.
Five teaspoons is equivalent to how many milliliters (ml)?
- A. 30 ml
- B. 25 ml
- C. 12 ml
- D. 22 ml
Correct Answer: B
Rationale: One teaspoon equals 5 ml, so 5 teaspoons is 25 ml.
It is best described as a systematic, rational method of planning and providing nursing care for individuals, families, group and community
- A. Assessment
- B. Nursing Process
- C. Diagnosis
- D. Implementation
Correct Answer: B
Rationale: The nursing process (B) is a comprehensive, systematic framework used by nurses to deliver patient-centered care. It encompasses five steps: assessment (data collection), diagnosis (identifying health problems), planning (setting goals and interventions), implementation (carrying out the plan), and evaluation (assessing outcomes). This definition matches the description in the question as a rational, organized method applicable to individuals, families, groups, and communities. Assessment (A) is only the first step, not the entire method. Diagnosis (C) is a single phase focused on problem identification, while implementation (D) is the action phase, neither encompassing the full scope described. The nursing process integrates critical thinking and evidence-based practice to ensure holistic care, making B the accurate answer reflecting its broad, systematic nature.
The name of the nursing diagnosis is linked to the etiology with the phrase:
- A. as manifested by'
- B. related to'
- C. evidenced by'
- D. due to'
Correct Answer: B
Rationale: In nursing diagnoses, a standardized format connects the problem to its cause. The phrase 'related to' is used to link the identified health issue, such as 'Impaired Mobility,' to its etiology, like 'joint stiffness,' forming a clear cause-and-effect relationship. 'As manifested by' and 'evidenced by' describe symptoms or signs supporting the diagnosis, not the cause. 'Due to' is less specific and not part of the formal nursing diagnosis structure outlined by NANDA International. This format ensures clarity in care planning, allowing nurses to address underlying causes effectively, enhancing patient outcomes through targeted interventions based on this relationship.