A nurse is collecting data from a client who has a score of 8 using the Glasgow Coma Scale. Which of the following findings should the nurse expect?

The client requires total nursing care.

The client is in a deep coma.

The client is alert and oriented.

The client has a stable neurological status.

Answer and Explanation

The Correct Answer is A

a. A GCS score of 8 indicates severe impairment, suggesting the client may be in a state where they cannot perform basic self-care activities and thus require total nursing care.

b. A GCS score of 8 indicates severe impairment but not necessarily a deep coma. Scores below 8 suggest a comatose state, but deep coma is more likely to be indicated by a score of 3-4.

c. A GCS score of 8 is not consistent with a client who is alert and oriented. This score indicates significant neurological impairment.

d. A GCS score of 8 does not indicate stable neurological status. It suggests severe impairment and potentially unstable or deteriorating neurological condition.

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Correct Answer is C

Explanation

The highest priority nursing intervention for a client who is unconscious following a stroke is to suction saliva from the client's mouth. This can help prevent aspiration and maintain a patent airway, which is essential for the client's survival.

Performing passive range of motion on each extremity, recording the client's intake and output, and monitoring the client's electrolyte levels are also important nursing interventions for this client. However, these interventions are not as high of a priority as maintaining a patent airway.

A. Keep the bed at a comfortable working height. B. Administer a sedative at bedtime. C. Keep a night light on in the client's room and bathroom. D. Place the bedside table within the client's reach. E. Lock the wheels on beds and wheelchairs during transfers.

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

Explanation

Keeping a night light on in the client's room and bathroom can help reduce the risk of falls by improving visibility and orientation at night. Placing the bedside table within the client's reach can help reduce the risk of falls by making it easier for the client to access necessary items without having to get up and move around. Locking the wheels on beds and wheelchairs during transfers can help reduce the risk of falls by providing stability and preventing unwanted movement.

Keeping the bed at a comfortable working height is important for the nurse's comfort and safety while providing care, but it does not directly reduce the risk of falls for the client.

Administering a sedative at bedtime may help the client sleep, but it can also increase the risk of falls by causing drowsiness and disorientation.

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A nurse is collecting data from a client who has a score of 8 using the Glasgow Coma Scale. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is unconscious following a stroke. Which of the following nursing interventions is of highest priority?

Correct Answer is C

Explanation

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

Explanation

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