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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 []

Explanation

Cardiovascular

- Capillary refill 4 seconds

- A prolonged capillary refill time indicates poor peripheral perfusion, which can be a sign of hypoxia. Hypoxia can lead to reduced oxygen delivery to the tissues, resulting in delayed capillary refill.

Respiratory

- Oxygen saturation 90% on room air

- An oxygen saturation level of 90% is below the normal range (95-100%) and indicates that the blood is not adequately oxygenated, which is a direct sign of hypoxia.

- Respiratory rate 28 breaths/minute

- An elevated respiratory rate (tachypnea) is a common compensatory mechanism in response to hypoxia. The body attempts to increase oxygen intake and carbon dioxide expulsion by breathing more rapidly.

Neurological

- Anxious

- Anxiety can be a symptom of hypoxia. When the brain and other vital organs do not receive enough oxygen, it can trigger a sense of anxiety and restlessness as part of the body's alarm system.

- Restless

- Restlessness is another common symptom of hypoxia. It occurs because the body is trying to compensate for the lack of oxygen, leading to increased agitation and an inability to remain
calm.

Rationales for the Incorrect Choices:

- Cardiovascular

- Heart rate 101 beats/minute: While an elevated heart rate can be a compensatory response to hypoxia, it alone does not directly indicate hypoxia.
- Blood pressure 145/89 mm Hg: Elevated blood pressure is not a direct indicator of hypoxia and can be influenced by various factors including anxiety and pain.

- Respiratory

- Productive cough: A productive cough suggests respiratory infection or inflammation but does not directly measure oxygenation status or indicate hypoxia.

- Neurological

- Awake and alert: Being awake and alert indicates normal mental status and does not suggest hypoxia. Hypoxia typically affects cognitive function, leading to confusion or decreased level of consciousness in more severe cases.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

Semi Fowler's position:

- This position involves raising the head of the bed to an angle of 30 to 45 degrees. It is

commonly used to improve respiratory function and comfort in patients who are experiencing

difficulty breathing. By elevating the head and torso, this position facilitates better lung expansion, helping to improve oxygenation.

Promote lung expansion:

- In patients with respiratory issues such as pneumonia, positioning that enhances lung expansion is critical. Semi Fowler's position helps to reduce pressure on the diaphragm, allowing for more effective lung expansion and improved oxygenation. This is particularly important for a patient with decreased breath sounds and consolidation in the lungs, as it aids in alleviating respiratory distress and improving gas exchange.

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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.

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Naxlex Comprehensive Predictor Exams

Exhibits here The nurse places the client on a cardiorespiratory monitor and places the nasal cannula on the client. The nurse then completes an assessment and documents it in the chart. For each body system, click to specify the assessment findings that indicates hypoxia.

Correct Answer is []

Explanation

Exhibits The nurse should place the client in a position to promote

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

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Exhibits Which 2 orders should the nurse complete first?

Exhibits

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