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.

Answer and Explanation

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.

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Correct Answer is ["B","C","D"]

Explanation

Exercise has many health benefits, such as improving self-concept, decreasing resting pulse and blood pressure, and improving sleep quality.

A. Chicken, carrots, and fresh grapefruit salad. B. Salmon, turnip greens, brown rice, and an orange. C. Green salad, ground beef patty, corn, and applesauce. D. Plain omelet, bacon, toast with butter, and strawberries.

Correct Answer is B

Explanation

This meal selection best demonstrates a client with osteoporosis understands dietary recommendations because it provides adequate amounts of calcium, vitamin D, and protein, which are essential nutrients for bone health.

Choice A is wrong because chicken, carrots, and fresh grapefruit salad do not provide enough calcium or vitamin D for a person with osteoporosis.

Calcium is mainly found in dairy products, leafy green vegetables, and fish with bones. Vitamin D is mainly found in fatty fish, egg yolks, and fortified foods.

Choice C is wrong because green salad, ground beef patty, corn, and applesauce do not provide enough calcium or vitamin D for a person with osteoporosis.

Green salad may contain some calcium depending on the type of greens, but it is not a rich source.

Ground beef patty and corn are low in calcium and vitamin

D. Applesauce does not contain any calcium or vitamin

D. Choice D is wrong because plain omelet, bacon, toast with butter, and strawberries do not provide enough calcium or vitamin D for a person with osteoporosis.

Plain omelet and bacon are high in protein but low in calcium and vitamin

Toast with butter may contain some vitamin D if the bread or butter are fortified, but it is not a rich source.

Strawberries do not contain any calcium or vitamin

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client about the benefits of exercise. The nurse knows teaching has been effective when the client lists which of the following health benefits of exercise? (Select all that apply).

Correct Answer is ["B","C","D"]

Explanation

Which meal selection best demonstrates a client with osteoporosis understands dietary recommendations?

Correct Answer is B

Explanation

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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?