The nurse is caring for a client with brain trauma who is in a coma. The client's Glascow Coma Scale is 6. Which response would the nurse expect the client to have?

Able to localize pain

Is verbally responsive, but confused

Moves arms as directed

Opens eye to deep pain only

Answer and Explanation

The Correct Answer is D

A. Able to localize pain: A score of 6 is too low for a client to localize pain, which would require higher motor function.

B. Is verbally responsive, but confused: Verbal responsiveness would require a higher score, as a GCS of 6 indicates severe impairment.

C. Moves arms as directed: Following commands is consistent with a higher GCS score.

D. Opens eyes to deep pain only: This response aligns with the minimal responsiveness expected for a GCS score of 6.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Decreased peripheral pulses. Decreased pulses may be related to poor perfusion but are not a hallmark sign of right-sided heart failure.

B. S3 heart murmur. An S3 heart murmur is associated with left-sided heart failure due to fluid overload in the lungs.

C. Distended neck veins: Right-sided heart failure leads to the backup of blood in the systemic circulation, which often causes jugular vein distention (JVD), peripheral edema, and hepatomegaly.

D. Orthopnea. Orthopnea is a symptom of left-sided heart failure, where fluid builds up in the lungs, making it difficult to breathe when lying flat.

A. Insertion of central venous access B. Phlebotomy C. Fasciotomy D. Insertion of arterial line

Correct Answer is C

Explanation

A. Insertion of central venous access: This is not relevant to compartment syndrome management. Central venous access is used for fluid administration or monitoring central venous pressure.

B. Phlebotomy: This is unrelated to the management of compartment syndrome, as it involves drawing blood and does not address the increased pressure.

C. Fasciotomy: Compartment syndrome is a medical emergency where increased pressure within a closed compartment compromises circulation and tissue function. A fasciotomy involves surgically opening the compartment to relieve the pressure, prevent tissue necrosis, and save the limb. This is the definitive treatment.

D. Insertion of arterial line: While this may be useful for monitoring blood pressure in critical situations, it does not relieve compartment syndrome.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is caring for a client with brain trauma who is in a coma. The client's Glascow Coma Scale is 6. Which response would the nurse expect the client to have?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client with decompensated heart failure. Which finding would indicate that the client is manifesting right-sided heart failure?

Correct Answer is C

Explanation

The nurse is caring for a client who sustained a crushed injury to the lower extremity and has developed compartment syndrome. What intervention should the nurse plan for next?

Correct Answer is C

Explanation

The nurse is caring for a client who is newly admitted with severe chest pain and suspected myocardial infarction. Which diagnostic blood test would be considered the most reliable and critical indicator of myocardial injury?

The nurse is educating a client diagnosed with mitral valve prolapse. What education will the nurse need to provide the client about this diagnosis? Possible Education

A client is being seen in the clinic to rule out mitral valve stenosis. Which assessment data would be an early indication of this condition?

The nurse is caring for a client with advanced coronary artery disease who has developed cardiac arrest. During the resuscitation, the health care provider prescribes atropine. Which is the intended outcome of this medication?

A client has been admitted with a head injury from a motor vehicle accident. Vital signs on admission were BP 120/80 mm Hg and pulse 88. Which vital signs would indicate that Cushing's triad was occurring?

The nurse is assigned to the cardiac unit caring for four clients. He is preparing to do initial rounds. Which client should the nurse assess first?

The nurse is teaching a group of staff nurses about myocarditis. What would the nurse identify as being potential risk factors for this condition? Select All That Apply

A nurse is caring for an alert client who reports heart palpitations, nausea, and dizziness. An electrocardiogram (EKG) confirms the client is experiencing vector tachycardia (VT). The nurse should anticipate which action?