The critical care nurse is giving end-of-shift report on a client.
The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female client and reports to the oncoming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate?
Stupor.
Somnolence.
Normal.
Deep coma.
The Correct Answer is D
Choice A rationale
Stupor refers to a state of near-unconsciousness or insensibility, where the patient can be briefly aroused by vigorous or repeated stimuli.
Choice B rationale
Somnolence refers to a state of strong desire for sleep or sleeping for unusually long periods (drowsiness), but it is not as severe as stupor or coma.
Choice C rationale
Normal consciousness means the patient is awake, alert, and responsive to their environment with no neurological deficits.
Choice D rationale
A score of 6 on the Glasgow Coma Scale indicates deep coma, where the patient has minimal to no response to stimuli, indicating severe brain injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Normal posture involves relaxed and symmetrical positioning of the limbs without any abnormal flexion or extension.
Choice B rationale
Decorticate posturing is characterized by abnormal flexion of the upper extremities at the elbows and wrists, and extension of the lower extremities, often indicating damage to the corticospinal tract.
Choice C rationale
Decerebrate posturing involves extension and outward rotation of both the arms and legs, indicating damage to the brain stem, which is more severe than decorticate posturing.
Choice D rationale
Flaccid posture refers to a complete lack of muscle tone and resistance, often seen in severe cases of neurological damage or after a stroke. .
Correct Answer is D
Explanation
Choice A rationale
Administering a bolus of normal saline may not directly address the cause of increased respiratory effort, which could be related to increased intracranial pressure (ICP). Normal saline administration is not the priority intervention in this case.
Choice B rationale
Bronchodilators are used to manage bronchoconstriction, not increased respiratory effort due to potential increased ICP. Monitoring the client's level of consciousness (LOC) is important, but bronchodilators are not indicated here.
Choice C rationale
Increasing the client's bed height can help with respiratory effort, but it does not directly address the potential underlying issue of increased ICP. Reassessing in 30 minutes might delay necessary interventions.
Choice D rationale
Increased respiratory effort in a client with a head injury may indicate rising ICP. Informing the care team and assessing for further signs of increased ICP is crucial for timely intervention to prevent further complications.
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