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The nurse is performing a Glasgow Coma Scale (GCS) assessment on a client with a problem with intracranial regulation. The client’s GCS one (1) hour ago was scored at 10. Which datum indicates the client is improving?
- A. The current GSC rating is 3.
- B. The current GSC rating is 9.
- C. The current GSC rating is 10.
- D. The current GSC rating is 12.
Correct Answer: D
Rationale: A GCS of 12 (D) is higher than 10, indicating improved neurological status. Scores of 3 (A) or 9 (B) indicate worsening, and 10 (C) shows no change.
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The client diagnosed with a gunshot wound to the head assumes decorticate posturing when the nurse applies painful stimuli. Which assessment data obtained three (3) hours later would indicate the client is improving?
- A. Purposeless movement in response to painful stimuli.
- B. Flaccid paralysis in all four extremities.
- C. Decerebrate posturing when painful stimuli are applied.
- D. Pupils that are 6 mm in size and nonreactive on painful stimuli.
Correct Answer: A
Rationale: Purposeless movement (A) indicates a higher level of brain function compared to decorticate posturing, suggesting improvement. Flaccid paralysis (B) or decerebrate posturing (C) indicates worsening, and nonreactive pupils (D) suggest severe brain damage.
Which nursing intervention is most appropriate after the lumbar puncture has been performed?
- A. Keep the client in a side-lying position.
- B. Assist the client into a sitting position.
- C. Withhold food and fluids for 1 hour.
- D. Keep the client flat for several hours.
Correct Answer: D
Rationale: Keeping the client flat for several hours post-lumbar puncture reduces the risk of cerebrospinal fluid leakage and subsequent headache.
The client is prescribed phenytoin (Dilantin), an anticonvulsant, for a seizure disorder. Which statement indicates the client understands the discharge teaching concerning this medication?
- A. I will brush my teeth after every meal.'
- B. I will check my Dilantin level daily.'
- C. My urine will turn orange while on Dilantin.'
- D. I won’t have any seizures while on this medication.'
Correct Answer: A
Rationale: Phenytoin can cause gingival hyperplasia, so good oral hygiene (A) is essential and indicates understanding. Dilantin levels (B) are checked periodically by providers, not daily. Urine color change (C) is not typical, and seizures may still occur (D) if not fully controlled.
The nurse is caring for several clients. Which client would the nurse assess first after receiving the shift report?
- A. The 22-year-old male client diagnosed with a concussion who is complaining someone is waking him up every two (2) hours.
- B. The 36-year-old female client admitted with complaints of left-sided weakness who is scheduled for a magnetic resonance imaging (MRI) scan.
- C. The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale (GCS) score of 6.
- D. The 62-year-old client diagnosed with a cerebrovascular accident (CVA) who has expressive aphasia.
Correct Answer: C
Rationale: A GCS score of 6 (C) indicates severe neurological impairment, requiring immediate assessment for potential life-threatening conditions. Waking every 2 hours (A) is standard for concussion, left-sided weakness (B) is concerning but less acute, and expressive aphasia (D) is stable.
The nurse caring for a client diagnosed with Parkinson’s disease writes a problem of 'impaired nutrition.' Which nursing intervention would be included in the plan of care?
- A. Consult the occupational therapist for adaptive appliances for eating.
- B. Request a low-fat, low-sodium diet from the dietary department.
- C. Provide three (3) meals per day that include nuts and whole-grain breads.
- D. Offer six (6) meals per day with a soft consistency.
Correct Answer: A
Rationale: PD can impair fine motor skills, making eating difficult. Consulting an occupational therapist (A) for adaptive appliances supports nutritional intake. Low-fat diets (B) are not specific, nuts/breads (C) may be hard to chew, and six soft meals (D) may not address motor issues.