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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Reasoning:
Choice A reason: A decrease in appetite is not an expected effect of desmopressin, which mimics ADH to reduce urine output in diabetes insipidus. Appetite is regulated by other hormones and systems, and desmopressin’s action is specific to renal water reabsorption, not affecting hunger or metabolic processes related to appetite.
Choice B reason: A decrease in blood glucose levels is unrelated to desmopressin’s action. Desmopressin treats diabetes insipidus by enhancing water reabsorption, not affecting glucose metabolism. Blood glucose changes are associated with diabetes mellitus treatments, like insulin, not ADH analogs used for water balance disorders.
Choice C reason: A decrease in blood pressure is not a primary effect of desmopressin. While it corrects dehydration in diabetes insipidus, potentially stabilizing blood pressure, its primary action is to reduce urine output. Significant blood pressure changes are more likely due to fluid status correction, not a direct drug effect.
Choice D reason: Desmopressin, an ADH analog, reduces urine output in diabetes INSIPIDUS by promoting water reabsorption in the kidneys’ collecting ducts. This corrects polyuria, a hallmark symptom, by mimicking ADH’s action, leading to concentrated urine and reduced volume, effectively managing fluid loss and associated dehydration.
Correct Answer is D
Explanation
Reasoning:
Choice A reason: Infection is not directly related to tissue hypoxia in iron deficiency anemia. Hypoxia results from low hemoglobin, reducing oxygen delivery, but it does not inherently cause infection. Infections may contribute to anemia in chronic disease but are not the primary issue in iron deficiency.
Choice B reason: Deficient fluid volume is not a primary concern in iron deficiency anemia. Impaired erythropoiesis reduces red blood cell production due to low iron, causing anemia, but fluid volume remains normal unless bleeding occurs. Fatigue from low oxygen capacity is more directly linked to the condition.
Choice C reason: Acute pain is not typical in iron deficiency anemia. Pain is associated with hemolytic anemias like sickle cell disease due to vaso-occlusion. Iron deficiency causes fatigue and dyspnea from low hemoglobin, not hemolysis or pain, making this an incorrect association.
Choice D reason: Fatigue related to decreased oxygen-carrying capacity is the most likely issue in iron deficiency anemia. Low iron impairs hemoglobin synthesis, reducing red blood cell oxygen transport, causing tissue hypoxia and fatigue, especially during exertion, directly reflecting the pathophysiology of the client’s condition.
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