A nurse is assessing an adult patient whose G
• A GCS score of eight or less defines coma. The lowest achievable score is three, which means deep coma. Fifteen is a perfect score.
• The Glasgow Coma Scale is a practical scale that independently evaluates three features including Best Eye Opening, Best Motor Response, and Best Verbal Response.
• Incorrect: The other options are incorrect because the lowest score that can be achieved is three points. A GCS score of nine does not indicate coma.
A patient with chronic obstructive pulmonary disease (COPD) is feeling short of breath and has an oxygen saturation of 86% on room air. The nurse auscultates inspiratory and expiratory wheezes. The nurse applies a nasal cannula at a rate of 2L per minute. What should the nurse do next?
A patient is being evaluated for abdominal pain. The nurse elicits Murphy's sign, or pain in the right upper quadrant along the costal margin. A positive Murphy's sign is indicative of:
The nurse is caring for a patient admitted for diabetes insipidus. During the physical assessment, the nurse should expect to note which of the following?
A patient with peptic ulcers is admitted to the hospital for a suspected perforation. While assessing the patient, the nurse would expect which common symptom of this complication?
The nurse is caring for a patient who has undergone an above-the-knee amputation (AKA). The nurse encourages the patient to begin exercising the affected limb:
A patient presents with increased intracranial pressure, papilledema, and headache. There is no history of trauma. Vital signs are BP of 120/70 mmHg, HR 90 bpm, Temp 98.9˚ F, Respirations 20 bpm. Given these assessment findings, the nurse thinks the patient may have
The goal of nursing care management in a client with osteoarthritis is
A patient admitted to the medical ward has a fever of 103˚ F, nuchal rigidity, pain on extension of the legs, and opisthotonos. Based on these findings, prioritize these nursing diagnoses:
1. Altered comfort: pain
2. Altered cerebral perfusion
4. High risk for injury
A nurse is monitoring the intracranial pressure (ICP) of a patient with a traumatic brain injury (TBI) from an MVA. Which of the following would the nurse
The nurse is assessing a patient who has a closed head injury. The patient presents with confusion, drowsiness, and unequal pupils. Which of the following nursing diagnoses takes priority?
During the health education of a patient with Parkinson's disease, one family member verbalizes a statement that needs further education. Which of the following statements should the nurse correct?
A patient diagnosed with lung cancer is receiving chemotherapy on an outpatient basis. The nurse must provide which of the following home care instructions to the patient?
A patient is scheduled to undergo an ultrasound to evaluate a renal mass. The nurse understands that an ultrasound is ordered, as opposed to other tests, because:
The nurse is caring for a patient in the advanced stages of cirrhosis. While making menu selections, the nurse should suggest increasing:
A patient with diabetes mellitus is admitted to the hospital with lower back pain. The patient's blood glucose is 563 mg/dl upon admission. Which assessment finding would the nurse most likely note with this blood glucose level?
The nurse is providing discharge instructions to a patient with Addison's disease. Which of the following patient statements is correct?
A patient is seen in the emergency department after abruptly discontinuing her thyroid medication. She is hypotensive, hypoglycemic, and is unresponsive. This clinical picture is most consistent with
The nurse is caring for a patient with hepatic encephalopathy. When advising him on menu options, the nurse tells the patient to avoid:
The nurse is providing instructions to a patient with a gastric ulcer. The patient is being treated with famotidine, and a bland diet. The nurse should instruct the patient to do which of the following?
The patient is to undergo insertion of a chest tube. Which statement shows that the patient needs further teaching?
The nurse is caring for a patient after undergoing a right thoracotomy. When caring for this patient with a chest tube, the nurse should
The nurse is assessing a patient with atrial fibrillation and a rapid ventricular rate. The nurse would expect to see
A patient with chronic hepatitis is admitted to the hospital due to his declining status. The nurse assesses the patient and will most likely note which of the following?
The nurse is caring for a patient that just underwent a bronchoscopy. The nurse should complete which of the following interventions?
The nurse is caring for a patient receiving chemotherapy. What precautions should the nurse take when handling bodily fluids for this patient?
A nurse is giving health education to a patient diagnosed with colorectal cancer. The patient's son asks the nurse what major factor increases the risk of a person having colorectal cancer. The nurse correctly answers the patient with