Fundamentals Nursing Process Questions

Fundamentals Nursing Process Questions Related

Review Fundamentals Nursing Process Questions related questions and content

The Glasgow coma scale is used to .evaluate the level of consciousness in the neurological and neurological patients. The three assessment factors included in this scale are:

  • A. pupil size, response to pain, motor responses
  • B. Pupil size, verbal response, motor response
  • C. Eye opening, verbal response, motor response
  • D. Eye opening, response to pain, motor response J.E, is an 18-year old freshman admitted to the ICU following a motor vehicle accident in which he sustained multiple trauma including a ruptured spleen, myocardial contusion, fractured pelvis, and fractured right femur. He had a mild contusion, but is alert and oriented. His vital signs BP 120/80, pulse 84, respirations 12, and temperature 99 F orally.
Correct Answer: C

Rationale: The correct answer is C: Eye opening, verbal response, motor response. The Glasgow Coma Scale (GCS) assesses the level of consciousness by evaluating these three factors. Eye opening assesses the patient's ability to open their eyes spontaneously or in response to stimuli. Verbal response evaluates the patient's ability to speak or respond to verbal stimuli. Motor response assesses the patient's motor function by testing responses to commands or painful stimuli. Choice A is incorrect because it includes "response to pain" instead of "verbal response." Choice B is incorrect because it includes "verbal response" instead of "eye opening." Choice D is incorrect because it includes "eye opening" instead of "verbal response." In summary, the GCS evaluates eye opening, verbal response, and motor response to determine the level of consciousness in patients.

You may also like to solve these questions

Which of the following is an early sign of anemia?

  • A. Palpitations
  • B. Pallor
  • C. Glossitis
  • D. Weight loss
Correct Answer: B

Rationale: The correct answer is B: Pallor. Pallor, which refers to paleness of the skin, is an early sign of anemia due to decreased red blood cell levels. Anemia causes reduced oxygen delivery to tissues, leading to paleness. Palpitations (A) may occur in anemia but are not an early sign. Glossitis (C) and weight loss (D) are not typically early signs of anemia and are more commonly associated with other health conditions.

A client is admitted to the hospital with a bleeding ulcer and is to receive 4 units of packed cells. Which nursing intervention is of primary importance in the administration of blood?

  • A. Checking the flow rate
  • B. Monitoring the vital signs
  • C. Identifying the client
  • D. Maintaining blood temperature
Correct Answer: C

Rationale: Step 1: Identifying the client is crucial for correct blood transfusion to avoid errors.
Step 2: Client identification includes verifying name, date of birth, and unique identifiers.
Step 3: Ensuring correct patient prevents transfusion reactions and improves patient safety.
Step 4: Monitoring vital signs and flow rate are important but secondary to client identification.
Step 5: Maintaining blood temperature is not a primary concern during blood transfusion.

The nursing care for the client in addisonian crisis should include which of the following interventions?

  • A. Encouraging independence with activities of daily living (ADL)
  • B. Allowing ambulation as tolerated
  • C. Offering extra blankets and raising the heat in the room to keep the client warm
  • D. Placing the client in a private room
Correct Answer: C

Rationale: The correct answer is C because in Addisonian crisis, the client experiences adrenal insufficiency leading to decreased cortisol levels and impaired stress response. Offering extra blankets and raising room temperature helps prevent hypothermia, as clients in crisis are unable to regulate body temperature. Encouraging independence with ADLs (choice A) and ambulation (choice B) are not priorities as the client is in a critical state. Placing the client in a private room (choice D) is not directly related to managing Addisonian crisis.

Mrs. Santos, a 75-year old patient with type II diabetes is in emergency department with signs of hyperglycemic, hyperosmolar nonketotic (HHNK) coma. What assessment finding should the nurse expect?

  • A. Fruity odor of the breath
  • B. shallow, deep respirations
  • C. severe dehydration
  • D. profuse sweating
Correct Answer: C

Rationale: The correct answer is C: severe dehydration. In HHNK coma, the body tries to eliminate excess glucose through frequent urination, leading to dehydration. This results in decreased blood volume, causing hypotension and tachycardia. Signs include dry mucous membranes, poor skin turgor, and concentrated urine output. Fruity odor of the breath (A) is associated with diabetic ketoacidosis, not HHNK coma. Shallow, deep respirations (B) and profuse sweating (D) are not typically associated with HHNK coma.

Which of the ff diets does the nurse recommend for clients with hypertension under the physicians guidance?

  • A. The Food Guide Pyramid
  • B. The South Beach Diet
  • C. The Step One Diet
  • D. The Dash diet
Correct Answer: D

Rationale: Step 1: The DASH diet is specifically designed to help lower blood pressure, making it the most appropriate choice for clients with hypertension.
Step 2: The DASH diet emphasizes fruits, vegetables, whole grains, lean proteins, and low-fat dairy, all of which are beneficial for managing hypertension.
Step 3: The diet also limits sodium intake, which is crucial for controlling blood pressure.
Step 4: The other options (A, B, and C) do not have the same evidence-based focus on hypertension management and may not be as effective in lowering blood pressure.

Copyright © 2025 Nokea. All rights reserved.