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 A

Explanation

Decreased flexibility is a normal age- related change that occurs in the elderly due to loss of elasticity in the ligaments and tendons.
Some possible explanations for the other choices are:
Choice B. Pain when standing. Pain when standing is not a normal finding and could indicate arthritis, osteoporosis, or injury.
Choice C. Swelling of the ankles. Swelling of the ankles is not a normal finding and could indicate heart failure, kidney disease, or venous insufficiency.
Choice D. Urinary incontinence. Urinary incontinence is not a normal finding and could indicate urinary tract infection, prostate enlargement, or neurological impairment.

A. Select an insulin syringe, 31 gauge 6 mm needle and inject insulin at a 45-degree angle. B. Select a 0.5 mL syringe, 30 gauge, 8 mm needle and inject at a 90-degree angle. C. Select a 0.5 mL syringe, 29 gauge 8 mm needle, pinch the skin, and inject at 45 degrees. D. Select a 1.0 mL syringe, 28 gauge 12.7 mm needle, and inject at 90 degrees.

Correct Answer is B

Explanation

Select a 0.5 mL syringe, 30 gauge, 8 mm needle and inject at a 90-degree angle. This is because Humulin R is a clear and colorless solution that can be given by subcutaneous injection.

A 0.5 mL syringe can hold up to 50 units of insulin, which is enough for the prescribed dose of 7 units. A 30 gauge, 8 mm needle is suitable for thin patients with poor skin turgor. Injecting at a 90-degree angle ensures that the insulin reaches the subcutaneous tissue and not the muscle.

Choice A is wrong because a 31 gauge, 6 mm needle is too short and may not deliver the insulin into the subcutaneous tissue.

Choice C is wrong because pinching the skin is not necessary for thin patients with poor skin turgor.

Choice D is wrong because a 1.0 mL syringe is too large for the prescribed dose of 7 units and may cause dosing errors. A 28 gauge, 12.7 mm needle is too long and may inject the insulin into the muscle, which can affect its absorption and action.

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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

Which assessment finding would be considered normal in an elderly client?

Correct Answer is A

Explanation

The client has diabetes Type I, a body mass index (BMI) of 17 and poor skin turgor. How should the nurse plan to administer the prescribed. Humulin R 7 units subcutaneously?

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?