Nokea
A client with a neurological disorder.
Which of the following nursing assessments will be MOST helpful in determining subtle changes in the client's level of consciousness?
- A. Client posturing.
- B. Glasgow coma scale.
- C. Client thinking pattern.
- D. Occurrence of hallucinations.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) indicates increased intracranial pressure (2) correct-Glasgow coma scale score best evaluates changes in a client's level of consciousness by evaluating eye-opening, motor, and verbal responses (3) more appropriate for the psychiatric client (4) more appropriate for the psychiatric client
You may also like to solve these questions
The nurse is caring for a client with a sigmoid colostomy who requests assistance in removing the flatus from a 1 piece drainable ostomy pouch. Which is the correct intervention?
- A. Piercing the plastic of the ostomy pouch with a pin to vent the flatus
- B. Opening the bottom of the pouch, allowing the flatus to be expelled
- C. Pulling the adhesive seal around the ostomy pouch to allow the flatus to escape
- D. Assisting the client to ambulate to reduce the flatus in the pouch
Correct Answer: B
Rationale: Opening the bottom of the pouch, allowing the flatus to be expelled, is the correct way to vent a 1-piece drainable ostomy pouch.
A client going to surgery tells the nurse that she is an active member of the Jehovah's Witness religion. The nurse is aware that the client's spiritual beliefs prohibit:
- A. The use of antibiotics and antivirals
- B. The use of medication from pork sources
- C. The eating of shellfish
- D. The use of blood or blood products
Correct Answer: D
Rationale: Jehovah's Witnesses prohibit blood transfusions and blood products due to religious beliefs. Other options are not typically restricted.
Which of these clients would the triage nurse request the provider examine immediately?
- A. A 5 month-old infant who has audible wheezing and grunting
- B. An adolescent who has soot over the face and shirt
- C. A middle-aged man with second degree burns over the right hand
- D. A toddler with singed ends of long hair that extends to the waist
Correct Answer: A
Rationale: A 5 month-old infant who has audible wheezing and grunting. The age and the findings suggest this client is at immediate risk for respiratory complications.
Which diagnosis for the client with tuberculosis would have the greatest impact on public health?
- A. Ineffective breathing pattern
- B. Deficient knowledge
- C. Fatigue
- D. Ineffective family therapeutic regimen management
Correct Answer: B
Rationale: Deficient knowledge about TB transmission risks public health by increasing spread, requiring education to ensure compliance with treatment and precautions.
The school nurse is teaching a group of preschool mothers about poison prevention in the home.
- A. Which statement by a mother indicates that further teaching is necessary?
- B. I should have a bottle of Ipecac for each of my children.'
- C. I should induce vomiting if my child swallows lighter fluid.'
- D. Giving my child water or milk may help dilute the poison.'
- E. Proper storage is the key to poison prevention in the home.'
Correct Answer: B
Rationale: Inducing vomiting after ingesting hydrocarbons like lighter fluid is contraindicated due to the risk of aspiration, which can cause severe lung damage. The other statements are correct: Ipecac is recommended for emergency use, diluting with water or milk can help, and proper storage is essential for prevention.