Nokea
A client who experienced a traumatic brain injury has a Glasgow Coma Scale score of 6 and is at risk for increased intracranial pressure (ICP). Which position should the nurse maintain for this client?
- A. Supine with head turned to the right
- B. Prone with the head straight
- C. Semi-Fowler's at 30 degrees
- D. High Fowler's at 90 degrees
Correct Answer: C
Rationale: For a GCS of 6 with ICP risk, semi-Fowler's at 30 degrees (C) optimizes venous drainage, reducing ICP. Supine (A) or prone (B) increases pressure. High Fowler's (D) may destabilize. C is correct. Rationale: 30-degree elevation balances ICP reduction and perfusion, per neurocare standards, critical in severe brain injury.
You may also like to solve these questions
The nurse uses the Glasgow Coma Scale to assess a client with a head injury. Which Glasgow Coma Scale score indicates that the client is in a coma?
- A. 6
- B. 9
- C. 12
- D. 15
Correct Answer: A
Rationale: A Glasgow Coma Scale (GCS) score of 6 (A) indicates coma, defined as ≤8, reflecting minimal responsiveness (eye, verbal, motor). Scores of 9 (B) and 12 (C) suggest moderate injury. 15 (D) is normal. A is correct. Rationale: GCS ≤8 signifies severe brain dysfunction, often requiring intubation, a standard threshold in neurocritical care for coma classification and management.
The nurse observes that Mr. Adams begins to have increased difficulty breathing. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. The nurse documents this breathing as:
- A. Tachypnea
- B. Eupnea
- C. Orthopnea
- D. Hyperventilation
Correct Answer: C
Rationale: Orthopnea is difficulty breathing relieved by an upright position.
A client with iron-deficiency anemia is taking an oral iron supplement. The nurse should tell the client to take the medication with:
- A. Orange juice
- B. Water only
- C. Milk
- D. Apple juice
Correct Answer: A
Rationale: Orange juice enhances iron absorption in iron-deficiency anemia via vitamin C, reducing ferric to ferrous form for better uptake a proven dietary aid. Milk inhibits it, water or apple juice lack this boost. Nurses teach this pairing, improving hemoglobin levels, optimizing therapy for fatigue and pallor relief.
Rommel told Budek, 'Do you think Im crazy?' Budek responded, 'Do you think your crazy?' Budek uses what example of therapeutic communication?
- A. Reflecting
- B. Restating
- C. Exploring
- D. Seeking clarification
Correct Answer: A
Rationale: Budek's 'Do you think you're crazy?' is reflecting (A), redirecting Rommel's question to explore his feelings or self-perception. Restating (B) repeats verbatim (e.g., 'You think you're crazy?'). Exploring (C) digs deeper (e.g., 'Why do you ask?'). Clarification (D) seeks meaning. Reflecting, per Peplau, fosters self-reflection, apt for Rommel's doubt, making A correct.
The nurse is completing a health history with an older adult client who reveals smoking one pack of cigarettes daily for the past 50 years. Which illness prevention strategy should the nurse recommend?
- A. Referral to a smoking cessation program
- B. Screening for lung cancer
- C. Referral to a nutritionist
- D. Mobility exercises
Correct Answer: A
Rationale: For an older adult with a 50-year, pack-a-day smoking history, the nurse prioritizes illness prevention via a smoking cessation program referral primary prevention to halt further damage from a modifiable risk tied to lung cancer, COPD, and heart disease. Quitting slashes these risks studies show even late cessation improves lung function. Screening for lung cancer is secondary, detecting issues, not preventing them, though relevant later. Nutrition or mobility exercises enhance wellness but don't address smoking's root threat 20% of smokers develop COPD. Cessation directly targets the habit, aligning with nursing's preventive ethos, offering practical support like group therapy or nicotine aids. This strategy empowers the client to alter a decades-long risk, maximizing health gains despite age, a cornerstone of tailored care.