Nokea
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.
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Which one of the following four clients is most likely to tolerate pain best?
- A. a client with rheumatoid arthritis
- B. a client who has terminal cancer in stage 1 of grief
- C. an athlete having a knee surgery to prolong his career
- D. a client who has a migraine headache
Correct Answer: C
Rationale: An athlete undergoing knee surgery likely tolerates pain best, motivated by career goals, unlike chronic arthritis, cancer grief, or migraines. Nurses consider this in pain management.
The nurse is preparing to take vital signs in an alert client admitted with dehydration secondary to vomiting and diarrhea. What is the best method to assess the client's temperature?
- A. Oral
- B. Axillary
- C. Radial
- D. Heat sensitive tape
Correct Answer: B
Rationale: Axillary is safest and most accessible for a dehydrated client with GI issues, avoiding oral route due to vomiting and diarrhea.
Marianne is now at the Defervescence stage of the fever, which of the following is expected?
- A. Delirium
- B. Goose flesh
- C. Cyanotic nail beds
- D. Sweating
Correct Answer: D
Rationale: Defervescence (decline) involves vasodilation and sweating e.g., cooling as heat dissipates. Delirium (high fever), goose flesh (chills), or cyanosis (hypoxia) don't fit. Nurses anticipate this e.g., damp sheets in Marianne, adjusting care, per fever stages.
Mr. Gary relied on the nurse for honest care. This is an example of?
- A. Trust
- B. Sympathy
- C. Health literacy
- D. Care coordination
Correct Answer: A
Rationale: Relying on honest care is trust (A) confidence in bond, per definition. Sympathy (B) pity, literacy (C) understanding, coordination (D) organization not trust-specific. A fits Mr. Gary's faith in the nurse, making it correct.
The nurse gave the wrong medication to Mr. Gary that lead to his cardiac arrest. This is an example of?
- A. Malpractice
- B. Negligence
- C. Assault
- D. Battery
Correct Answer: A
Rationale: Wrong medication causing cardiac arrest is malpractice (A) breach of nursing standards, per tort law. Negligence (B) is broader, assault (C) intent-based, battery (D) touch-based. A's professional error fits, making it correct.