A patient came into the emergency room after hitting his head on the floor during a basketball game. The nurse is obtaining a Glasgow Coma Score on the patient. The score is as follows:
Best Eye Opening = 3
Best Motor Response = 6
Best Verbal Response = 4
Total GCS = 13
The nurse interprets these findings as:
• The Glasgow Coma Scale is a standardized system for assessing the degree of neurologic impairment. A score of 15 indicates that a patient is awake and oriented, while a score of 8 or below means a patient is considered comatose. It is composed of three subscales, including Best Eye Opening, Best Motor Response and Best Verbal Response
• When a person opens his/her eyes to speech, he/she is given 3 points as Best Eye Opening
• When a person obeys verbal commands, he/she is given 6 points as Best Motor Response
• When a person shows confusion during
• The total GCS in this example is 13 (minor)
A newly diagnosed diabetic patient asks the nurse about the signs and symptoms of hypoglycemia. The nurse would include which of the following symptoms?
A newly diagnosed diabetic is receiving consultation about the disease process. The nurse explains that insulin is normally secreted from the:
A 43-year-old male is seen at the clinic with complaints of weight gain, bruising, and weakness. The patient is diagnosed with Cushing's syndrome, most likely caused by a(n):
The 68-year-old patient is admitted to the cardiac unit with endocarditis. The patient asks how someone catches this illness. Which of the following would you include when explaining risk factors of endocarditis to the patient?
The nurse is caring for a patient suspected of having lung cancer. The physician performs a bronchoscopy to obtain a biopsy. Which of the following should be reported to the physician?
The nurse is caring for a patient that has a carcinoma with no changes in the DNA structure and no viral infections found. What theory of carcinogenesis would this fall under?
A nurse is caring for a patient who has left-sided weakness due to a stroke. To avoid the risk of disuse syndrome, the nurse should do which of the following? Select all that apply.
A nurse is caring for a client who underwent thoracic surgery. Which among the following should the nurse perform to assess for manifestations of tension pneumothorax?
A patient is admitted after complaints consistent with hepatitis A. The patient's blood tests confirm this diagnosis. The nurse should expect to observe which symptoms?
The nurse is preparing a care plan for a patient with ascites related to cirrhosis. Which of the following nursing diagnoses should take priority?
A patient with chronic ulcerative colitis is seen in the clinic for a follow-up. The nurse reads the physician's note which states that the patient's disease is severe. The nurse would expect which of the following complications associated with chronic ulcerative colitis?
A patient with recurrent cystitis is receiving instructions by the nurse. To help prevent recurring cystitis, the nurse recommends the patient eat an acid-ash diet to acidify the urine. Which of the following should the patient avoid?
A nurse is caring for a patient who is scheduled to have a barium enema the following day to check for the presence of colon polyps. When the nurse enters the patient's room during rounds, which of the following should alert the nurse?
The nurse is caring for a patient with Parkinson's disease, who has been identified as a high risk for falls. Which of the following symptoms would the nurse associate with Parkinson's and a risk for falls?
The nurse is assessing the cardiac rhythm of a patient with coronary artery disease (CAD). The heart monitor shows isolated premature ventricular contractions (PVC). What should the nurse do next?
The nurse is assessing a patient with acute chest pain. Which of the following indicates angina pectoris?
A sedated patient is at risk for the development of pressure ulcers. Which of the following nursing interventions is appropriate for the prevention of pressure ulcers?
The nurse is providing discharge instructions to a patient with Addison's disease. Which of the following patient statements is correct?
The nurse is performing her routine physical assessment on a patient with Cushing's syndrome. Which of the following assessment findings is the nurse most likely to discover?
The nurse is assessing a patient with Cushing's syndrome for complications associated with hypercortisolism, including:
A nurse is preparing to administer SQ insulin into the abdomen of a patient. The patient asks why the abdomen is used instead of the arm. The nurse understands that:
While assessing a patient suspected of having hypothyroidism, the nurse would expect to observe which of the following symptoms?
The nurse is counseling a patient with anemia on iron-rich foods. Which of the following foods should the patient be encouraged to eat?
A 78-year-old man has osteoarthritis of the right hip and requires a cane in order to ambulate. While instructing the patient how to use a cane, the nurse should tell the patient to:
A 50-year-old male is diagnosed with end-stage renal failure. His current condition indicates the need for dialysis and is prescribed to follow a low-protein diet. This diet prescription is based on the principle that:
A patient is admitted to the hospital with 4th degree burns. The nurse expects the patient's wounds to be:
The nurse is caring for a patient with an adenocarcinoma involving the entire left lung with poor cellular differentiation. Metastases is discovered in the thyroid and numerous regional lymph nodes. Which of the following is the correct staging?
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 caring for a patient with an indwelling catheter. Which of the following nursing actions should be taken to help prevent catheter-associated urinary tract infections (CAUTI)?
When performing a skin examination on a 73-year-old male, the nurse should be alert for which characteristics of a malignant lesion?