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Exhibits

Which may have caused the change in the Glasgow Coma Scale score between 2000 and 2400? Select all that apply.

The client may be developing sepsis.

The client may be dehydrated.

The client may have increasing symptoms of head injury.

The client may have been sleeping.

The client may be improving clinically.

The client may require more morphine

The client may be experiencing sedative effects of morphine.

Answer and Explanation

Correct Answer : C,D,G

A. The client may be developing sepsis.

Sepsis typically presents with symptoms such as fever, increased heart rate, increased respiratory rate, and altered blood pressure. There is no indication of these signs in the provided data,
making sepsis an unlikely cause for the change in the Glasgow Coma Scale (GCS) score.

B. The client may be dehydrated.

Dehydration can affect cognitive function, but there is no evidence suggesting dehydration in this scenario (e.g., normal heart rate, blood pressure, and no noted intake/output imbalance).
C. The client may have increasing symptoms of head injury.

A decrease in GCS score can indicate worsening head injury symptoms, such as increased intracranial pressure or bleeding.
D. The client may have been sleeping.

Sleeping can temporarily affect the GCS score, particularly the eye-opening component.

E. The client may be improving clinically.

Improvement clinically would likely result in a stable or improved GCS score, not a decrease.

F. The client may require more morphine.

Needing more morphine would typically be due to increased pain, but this should not directly affect the GCS score unless severe pain is causing altered consciousness, which is not indicated here.
G. The client may be experiencing sedative effects of morphine.

Morphine, especially given intravenously, can cause sedation, which could lower the GCS score.

H. The client may need food.

Needing food would not typically cause an immediate change in GCS score unless associated with severe hypoglycemia, which is not indicated by the provided data.

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Correct Answer is A

Explanation

A. An adult client with no postoperative drainage in the Jackson-Pratt drain with the bulb compressed. This client is stable with no drainage from the Jackson-Pratt drain, indicating that there is no immediate issue that needs to be addressed. The bulb is compressed, suggesting proper function. Therefore, this client can be safely assessed last.
B. An adult client with a rectal tube draining clear, pale red liquid drainage. The presence of pale red drainage can indicate a potential issue that needs monitoring, such as bleeding or other complications, thus requiring a more timely assessment.

C. An older client with a distended abdomen and no drainage from the nasogastric tube. A distended abdomen and lack of drainage could indicate a blockage or other serious issue that needs immediate attention.
D. An older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac. Dark red drainage can indicate active bleeding, which is a critical issue that needs to be addressed promptly to prevent complications.

A. Administer aspirin to prevent further clot formation and platelet clumping. B. Raise the head of the bed to 30 degrees keeping head and neck in neutral alignment. C. Begin continuous observation for transient episodes of neurologic dysfunction. D. Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.

Correct Answer is D

Explanation

A. Administer aspirin to prevent further clot formation and platelet clumping. While aspirin may be indicated in the treatment of ischemic stroke, it is not the immediate priority. The client requires further assessment and diagnostic evaluation before initiating specific treatments.
B. Raise the head of the bed to 30 degrees keeping head and neck in neutral alignment.
Positioning the client is important for maintaining airway patency, but it is not the priority when assessing and managing acute stroke. Immediate interventions to address potential thrombolytic therapy take precedence.
C. Begin continuous observation for transient episodes of neurologic dysfunction. Continuous observation is important for monitoring the client's neurological status, but it is not the first action to take. The client requires urgent diagnostic imaging to confirm the diagnosis and
determine eligibility for thrombolytic therapy.

D. Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy. This is the priority action. IV access is crucial for administering medications and fluids, and reviewing the inclusion criteria for IV fibrinolytic therapy is essential to determine if the client meets the
criteria for this time-sensitive intervention.

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Exhibits Which may have caused the change in the Glasgow Coma Scale score between 2000 and 2400? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After receiving report, the nurse can most safely plan to assess which client last?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

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Exhibits Which 2 orders should the nurse complete first?

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Exhibits

Which may have caused the change in the Glasgow Coma Scale score between 2000 and 2400? Select all that apply.