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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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The nurse cares for 4 clients. Which activity demonstrates the nurse's understanding of how ethnicity influences the client's health?
- A. Provide financial resources from local organizations to pay for a client's health care needs.
- B. Teach a client using drawings, repetition, short sentences, and simple language.
- C. Assess a 5-month-old African American client for sickle cell anemia.
- D. Explain the consequences of not exercising and only eating fast food due to a stressful job.
Correct Answer: C
Rationale: Ethnicity influences health through genetic predispositions and cultural factors. Assessing a 5-month-old African American client for sickle cell anemia (C) reflects this, as the disease is prevalent in African descent populations due to a genetic mutation. Providing financial resources (A) addresses access, not ethnicity-specific health. Teaching with simple methods (B) aids comprehension but isn't ethnicity-tied. Diet and exercise advice (D) is general, not ethnic-specific. C is correct. Rationale: Sickle cell anemia's higher incidence in African Americans requires early screening to prevent complications like vaso-occlusive crises, showcasing culturally competent care rooted in genetic epidemiology, unlike the other options.
In what phase of Nurse patient relationship does a nurse review the client's medical records thereby learning as much as possible about the client?
- A. Pre Orientation
- B. Orientation
- C. Working
- D. Termination
Correct Answer: A
Rationale: In the Pre-Orientation phase (A), the nurse reviews records to gather data about the client before meeting, preparing for interaction. Orientation (B) begins with the first encounter, building trust. Working (C) involves goal-focused collaboration, and Termination (D) ends the relationship. Pre-Orientation is distinct as it's preparatory, not interactive, aligning with Peplau's model where understanding the client starts pre-contact, making A correct.
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.
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 caring for a client following a right total hip replacement. Which action by the nurse will help prevent dislocation of the prosthesis?
- A. Keeping the client's knees together at all times
- B. Placing the client in a supine position with the legs extended
- C. Placing a pillow between the client's legs when turning
- D. Encouraging the client to use the trapeze to pull himself up in bed
Correct Answer: C
Rationale: Placing a pillow between the legs during turning maintains abduction, preventing hip prosthesis dislocation post-right total hip replacement knees together adducts, supine extension risks posterior dislocation, and trapeze use is safe but unrelated. Nurses enforce this, ensuring joint stability, key for orthopedic recovery.