A nurse is reviewing the trend of a client’s scores on the Glasgow Coma Scale (GCS). This provides what potential information to the nurse about the client’s status?

An in-depth and real-time neurological assessment of the client’s condition

The client’s level of knowledge about preceding events

An assessment of the client’s current level of consciousness

An assessment of the client’s lowest verbal and physical response to stimuli

Answer and Explanation

The Correct Answer is C

Reasoning:

Choice A reason: The Glasgow Coma Scale (GCS) provides a standardized score for consciousness, not an in-depth neurological assessment. It evaluates eye, verbal, and motor responses but does not detail specific neurological deficits like cranial nerve function, requiring additional tests for a comprehensive neurological evaluation.

Choice B reason: The GCS does not assess knowledge of preceding events, which relates to memory or orientation, not consciousness. Amnesia or cognitive deficits are evaluated separately. The GCS focuses on immediate responses to stimuli, providing a snapshot of consciousness, not historical knowledge.

Choice C reason: The GCS assesses the client’s current level of consciousness by scoring eye opening, verbal response, and motor response. Trending scores over time indicates changes in consciousness, reflecting neurological status in conditions like head injury, guiding interventions and prognosis in critical care settings.

Choice D reason: The GCS does not measure the “lowest” verbal and physical response but the best response to stimuli at the time of assessment. It quantifies consciousness, not minimal function. Scores reflect current neurological status, not the worst possible responses, making this inaccurate.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Reasoning:

Choice A reason: Difficulty falling asleep is not a specific symptom of iron deficiency anemia. While fatigue is common, it affects energy levels, not sleep onset. Insomnia may result from other causes like anxiety or neurological conditions, not the reduced oxygen-carrying capacity of iron deficiency anemia.

Choice B reason: Difficulty breathing when walking 30 feet, or exertional dyspnea, is a hallmark of iron deficiency anemia. Low hemoglobin reduces oxygen delivery to tissues, causing shortness of breath during activity as the body struggles to meet oxygen demands, making this a key subjective symptom.

Choice C reason: Increased appetite is not typical in iron deficiency anemia. Some patients experience pica, craving non-food items, but not increased food appetite. Anemia causes fatigue and weakness, not hunger, which is more associated with metabolic or endocrine disorders, not iron deficiency.

Choice D reason: Feeling hot all the time is not a symptom of iron deficiency anemia. Patients often feel cold due to reduced oxygen delivery impairing thermoregulation. Feeling hot suggests hyperthyroidism or infection, not the hypoxic or circulatory issues characteristic of iron deficiency anemia.

A. A blood pressure reading of 120/85 mm Hg B. Pitting edema in the lower extremities C. Normal skin turgor D. Moist mucous membranes

Correct Answer is D

Explanation

Reasoning:

Choice A reason: A blood pressure reading of 120/85 mm Hg is normal but not specific to SIADH. While fluid overload in SIADH may elevate blood pressure, this reading is not diagnostic. Hypertension is possible but not a consistent finding, as fluid retention primarily causes hyponatremia and other symptoms.

Choice B reason: Pitting edema in the lower extremities is uncommon in SIADH, as fluid retention is primarily intravascular, leading to dilutional hyponatremia rather than extravascular edema. Edema is more typical in conditions like heart failure or nephrotic syndrome, not the water retention mechanism of SIADH.

Choice C reason: Normal skin turgor is not typical in SIADH, as water retention can cause slight fluid overload, potentially leading to subtle tissue swelling. While not as pronounced as edema, skin turgor may be slightly increased due to excess fluid, making “normal” less accurate than moist mucous membranes.

Choice D reason: Moist mucous membranes are expected in SIADH due to excessive water retention from ADH overactivity. This leads to fluid overload, keeping mucosal tissues hydrated and moist, unlike the dehydration seen in diabetes insipidus, which causes dry mucous membranes due to water loss.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is reviewing the trend of a client’s scores on the Glasgow Coma Scale (GCS). This provides what potential information to the nurse about the client’s status?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is collecting data for a client who has been diagnosed with iron-deficiency anemia. What subjective findings does the nurse recognize as symptoms related to this type of anemia?

Correct Answer is B

Explanation

A nurse is assessing a client admitted with SIADH. What finding would the nurse expect to assess in a client with SIADH?

Correct Answer is D

Explanation

A nurse is caring for a client with Cushing’s syndrome. Which interventions would the nurse include in the client’s plan of care? (Select all that apply)

The most common cause of iron deficiency anemia in male clients and postmenopausal female clients is:

A client is brought to the ED by family after falling off the roof. The care team suspects an epidural hematoma, prompting the nurse to anticipate which priority intervention?

A nurse suspects that a client may have aplastic anemia based on clinical manifestations and assessment. Which one of the following lab results would be consistent with this diagnosis?

The nurse assesses a client who has been diagnosed with Addison's disease. Which of the following is a diagnostic sign of this disease?

A client who has experienced an ischemic stroke has been admitted to the medical unit. The client’s family is adamant that the client remain on bed rest to hasten recovery and to conserve energy. What principle of care should inform the nurse’s response to the family?

Which of the following assessments should the nurse perform to determine the development of peptic ulcers when caring for a client with Cushing's syndrome?

A client has a history of sickle cell anemia with several sickle cell crises over the past 10 years. What blood component results in sickle cell anemia?