When providing nursing care to a client, the nurse provides family-centered nursing care. What is the best rationale for this nursing action?

The nurse does not want the client to feel lonely.

The client will be more compliant with medical instructions.

The family will be more willing to listen to instructions.

Illness in one family member can affect the other family members.

Answer and Explanation

The Correct Answer is D

Illness in one family member can affect the other family members. This is because family-centered nursing care recognizes that the family is the basic unit of society and that each member's health influences the whole family's health. Family-centered nursing care also involves collaborating with the family to provide care that meets their needs, preferences, and values.

Choice A is wrong because the nurse does not provide family-centered nursing care to avoid the client’s loneliness. Loneliness is a psychosocial need, not a physiologic one, and it can be addressed by other means than involving the family.

Choice B is wrong because the client’s compliance with medical instructions is not the primary goal of family-centered nursing care. Compliance is influenced by many factors, such as motivation, education, culture, and trust, and it may not always depend on the family’s involvement.

Choice C is wrong because the family’s willingness to listen to instructions is not the main reason for providing family-centered nursing care. The nurse should respect the family’s autonomy and decision-making, and not impose instructions that may conflict with their beliefs or values.

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Correct Answer is D

Explanation

Ineffective Airway Clearance. This is because a client with a Glasgow Coma Scale (GCS) of 6 has a severe impairment of consciousness and is at risk of aspiration, respiratory failure, and infection. The GCS is a clinical scale that measures a person’s level of consciousness after a brain injury based on their eye, verbal and motor responses. A GCS score of 6 indicates that the client only opens eyes to pain, makes incomprehensible sounds and shows abnormal flexion to pain.

Choice A is wrong because Acute Confusion is not a priority nursing diagnosis for a client with a GCS of 6.

Acute Confusion is a state of disorientation and impaired memory that can be caused by various factors such as medication, infection, electrolyte imbalance or dementia.

A client with a GCS of 6 is not likely to be confused, but rather unresponsive or minimally responsive.

Choice B is wrong because Self-Care Deficit is not a priority nursing diagnosis for a client with a GCS of 6.

Self-care deficit is the impaired ability to perform activities of daily living such as bathing, dressing, feeding or toileting.

A client with a GCS of 6 will need assistance with all these activities, but the most urgent concern is their airway patency and oxygenation.

Choice C is wrong because Risk for Impaired Skin Integrity is not a priority nursing diagnosis for a client with a GCS of 6.

Risk for Impaired Skin Integrity is the potential for damage to the skin or underlying tissues due to pressure, friction, shear or moisture.

A client with a GCS of 6 may be at risk for developing pressure ulcers or skin breakdown due to immobility and reduced sensation, but this is not as life-threatening as ineffective airway clearance.

A. pH, 7.32; pCO2, 47 mm Hg; HCO3, 29 mEq/L; pO2, 80. B. pH, 7.34; pCO2, 49 mm Hg; HCO3, 27 mEq/L; pO2, 77. C. pH, 7.38; pCO2, 40 mm Hg; HCO3, 25 mEq/L; pO2, 88. D. pH, 7.48; pCO2, 43 mm Hg; HCO3, 23 mEq/L; pO2, 85.

Correct Answer is C

Explanation

This is because it shows a normal pH, pCO2, HCO3 and pO2, indicating that the treatment has been effective in restoring normal gas exchange and acid- base balance.

Choice A is wrong because it shows a low pH, high pCO2 and high HCO3, indicating a mixed respiratory and metabolic acidosis.

Choice B is wrong because it shows a low pH, high pCO2 and low HCO3, indicating a combined respiratory and metabolic acidosis.

Choice D is wrong because it shows a high pH, low pCO2 and low HCO3, indicating a mixed respiratory and metabolic alkalosis.

The normal ranges for arterial blood gas (ABG) are:

pH: 7.35 – 7.45
pO2: 10 – 14 kPa or 75 – 105 mmHg
pCO2: 4.5 – 6 kPa or 34 – 45 mmHg

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When providing nursing care to a client, the nurse provides family-centered nursing care. What is the best rationale for this nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse assessment of a client diagnosed with an acute loss of consciousness reveals a Glasgow Coma Scale (GCS) of 6. Which nursing diagnosis is the priority?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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