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
This is because the first priority for assessing an elderly client who has become confused since admission is to rule out hypoxia, which can cause or worsen delirium. Hypoxia can result from various conditions, such as pneumonia, pulmonary embolism, or heart failure.
Oxygen saturation measurement is a quick and non-invasive way to assess the oxygen level in the blood and identify hypoxia.
Choice B. Review of current medications is wrong because although medications can cause or contribute to confusion and delirium in older adults, they are not the most urgent assessment to perform.
Medications should be reviewed after ensuring adequate oxygenation and addressing other possible causes of confusion.
Choice C. Intake and output last 24 hours is wrong because although dehydration and electrolyte imbalance can cause or worsen confusion and delirium in older adults, they are not the most urgent assessment to perform.
Intake and output should be monitored after ensuring adequate oxygenation and addressing other possible causes of confusion.
Choice D. Use of hearing aids or glasses is wrong because although sensory impairment can cause or worsen confusion and delirium in older adults, it is not the most urgent assessment to perform.
The use of hearing aids or glasses should be ensured after ensuring adequate oxygenation and addressing other possible causes of confusion.
Normal ranges for oxygen saturation are 95% to 100% for healthy adults. Lower levels may indicate hypoxia or other respiratory or cardiac problems.
Correct Answer is D
Explanation
A back massage is a type of cutaneous stimulation that can help reduce pain by activating the gate control theory of pain. Cutaneous stimulation is a non-pharmacological intervention that can be delegated to unlicensed assistive personnel (UAP) or nursing assistive personnel (NAP) under the supervision of a registered nurse.
Choice A is wrong because assessing pain status requires critical thinking and clinical judgment, which are skills that only registered nurses have. Pain assessment is not a task that can be delegated to UAP/NAP.
Choice B is wrong because administering a placebo is a type of pharmacological intervention that involves giving a substance that has no therapeutic effect. Placebos are unethical and ineffective for pain management and should not be used by any health care provider.
Choice C is wrong because reviewing a pain diary involves evaluating the patient’s response to pain interventions and adjusting the plan of care accordingly. This is a complex task that requires nursing knowledge and skills and cannot be delegated to UAP/NAP.
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