A nurse assessment of a client diagnosed with an acute loss of consciousness reveals a Glasgow Coma Scale (GCS) of 6.
Which nursing diagnosis is the priority?
Acute Confusion.
Self-Care Deficit.
Risk for Impaired Skin Integrity.
Ineffective Airway Clearance.
The Correct Answer is D
Ineffective Airway Clearance. This is because a client with a Glasgow Coma Scale (GCS) of 6 has a severe impairment of consciousness and is at risk of aspiration, respiratory failure, and infection. The GCS is a clinical scale that measures a person’s level of consciousness after a brain injury based on their eye, verbal and motor responses. A GCS score of 6 indicates that the client only opens eyes to pain, makes incomprehensible sounds and shows abnormal flexion to pain.
Choice A is wrong because Acute Confusion is not a priority nursing diagnosis for a client with a GCS of 6.
Acute Confusion is a state of disorientation and impaired memory that can be caused by various factors such as medication, infection, electrolyte imbalance or dementia.
A client with a GCS of 6 is not likely to be confused, but rather unresponsive or minimally responsive.
Choice B is wrong because Self-Care Deficit is not a priority nursing diagnosis for a client with a GCS of 6.
Self-care deficit is the impaired ability to perform activities of daily living such as bathing, dressing, feeding or toileting.
A client with a GCS of 6 will need assistance with all these activities, but the most urgent concern is their airway patency and oxygenation.
Choice C is wrong because Risk for Impaired Skin Integrity is not a priority nursing diagnosis for a client with a GCS of 6.
Risk for Impaired Skin Integrity is the potential for damage to the skin or underlying tissues due to pressure, friction, shear or moisture.
A client with a GCS of 6 may be at risk for developing pressure ulcers or skin breakdown due to immobility and reduced sensation, but this is not as life-threatening as ineffective airway clearance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Cataracts are a condition where the lens of the eye becomes opaque, causing impaired vision. Blurred or cloudy vision is a common symptom of cataracts.
Some possible explanations for the other choices are:
Choice B. Burning sensation in the eye. This is not a typical symptom of cataracts, but it could indicate an infection, allergy, or dry eye syndrome.
Choice C. Inability to produce tears. This is also not a typical symptom of cataracts, but it could indicate a problem with the lacrimal glands or ducts that produce and drain tears.
Choice D. A swollen lacrimal gland. This is not a symptom of cataracts, but it could indicate an inflammation or infection of the lacrimal gland, which is located near the upper eyelid.
Normal ranges for visual acuity are 20/20 for normal vision and 20/40 for mild impairment. Visual acuity can be measured using a Snellen chart or other methods.
Correct Answer is B
Explanation
This is because acute pain is the most urgent and life-threatening problem for a client with myocardial infarction.
Acute pain indicates ongoing ischemia and tissue damage, which can lead to complications such as heart failure, arrhythmias, or cardiogenic shock. Therefore, relieving pain is the priority nursing diagnosis.
Choice A. Anxiety is wrong because anxiety is not a specific symptom of myocardial infarction and anxiety is due to the discomfort that happens due to activation of the sympathetic pathway which is good for survival.
Choice C. Knowledge deficit is wrong because knowledge deficit is not an immediate problem for a client with myocardial infarction.
Knowledge deficit can be addressed after the acute phase of the condition is over and the client is stable.
Choice D. Nausea and vomiting are wrong because nausea and vomiting are common symptoms of myocardial infarction, but they are not as urgent and life-threatening as acute pain.
Nausea and vomiting can be treated with antiemetics and fluids, but they do not affect the outcome of the condition as much as pain does.
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