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.

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Correct Answer is D

Explanation

Reasoning:

Choice A reason: Diabetes insipidus causes hypernatremia due to excessive water loss from ADH deficiency, leading to polyuria and dehydration. This increases serum sodium concentration, not dilutional hyponatremia, which is characterized by low sodium due to water retention, making DI incorrect for this condition.

Choice B reason: Hypothyroidism affects metabolism through low thyroid hormone levels, causing symptoms like fatigue and weight gain. It does not directly cause dilutional hyponatremia, as it does not involve ADH or water retention. Sodium imbalances in hypothyroidism are rare and not dilutional in nature.

Choice C reason: Hyperthyroidism increases metabolism but does not typically cause dilutional hyponatremia. It may lead to dehydration from increased metabolic demand, but this does not involve excessive water retention or ADH dysfunction, which are necessary for dilutional hyponatremia to occur.

Choice D reason: SIADH causes dilutional hyponatremia due to excessive ADH, leading to water retention in the kidneys. This dilutes serum sodium, lowering its concentration. The increased fluid volume without corresponding sodium retention is the hallmark of SIADH, making it the correct endocrine disorder.

A. Chest radiograph B. ECG C. CBC D. Antibiotic

Correct Answer is C

Explanation

Reasoning:

Choice A reason: A chest radiograph evaluates lung or cardiac issues but is not the first test for symptoms of tiredness, coldness, and shortness of breath with tachycardia. These suggest anemia, and a CBC directly assesses hemoglobin and red blood cell counts, making it more relevant than imaging for initial evaluation.

Choice B reason: An ECG assesses cardiac rhythm and ischemia, useful for tachycardia, but it does not address the underlying cause of fatigue, coldness, and dyspnea. These symptoms suggest anemia, and a CBC is needed to confirm low hemoglobin before evaluating cardiac function with an ECG.

Choice C reason: A complete blood count (CBC) is the most appropriate test, as tiredness, coldness, shortness of breath, and tachycardia suggest anemia. A CBC measures hemoglobin, hematocrit, and red blood cell indices, identifying anemia’s presence and type, guiding further diagnostic and therapeutic interventions for the client’s symptoms.

Choice D reason: Antibiotics treat infections, but tiredness, coldness, dyspnea, and tachycardia point to anemia, not infection. Without fever or infection signs, antibiotics are inappropriate. A CBC is needed to confirm anemia as the cause, making it the priority over empirical antibiotic therapy.

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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

Which endocrine disorder causes the client to have dilutional hyponatremia?

Correct Answer is D

Explanation

A client reports feeling tired, cold, and short of breath at times. Assessment reveals tachycardia and reduced energy. What would the nurse expect the health care provider to order?

Correct Answer is C

Explanation

An adult client has been diagnosed with iron deficiency anemia. Which is most likely based on this client’s health status?

A client has just been diagnosed with an aneurysm. When planning discharge teaching for this client, what instructions should the nurse provide to the client?

Which is a clinical manifestation of diabetes insipidus?

A client with a neurological disorder has difficulty swallowing. The nurse should take special care with the client’s diet because of a potential risk of imbalanced nutrition. Which measure may be taken by the nurse to ensure that the client’s diet allows for easy swallowing?

A nurse is caring for a client with the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which finding would indicate that the client has developed fluid overload?

A client with a new diagnosis of ischemic stroke was treated in the ED with tissue plasminogen activator (t-PA) and then admitted to the ICU. In addition to closely monitoring the client’s cardiac and neurologic status, the nurse monitors the client for signs of what complication?

A client is being successfully treated for Cushing's syndrome. The nurse should expect a decline in: