A client is admitted to the emergency department after a motor vehicle accident. The client has a Glasgow Coma Scale (GCS) score of 10. What does this score indicate?

Correct Answer: B

Rationale: The correct answer is B) Moderate impairment. The Glasgow Coma Scale (GCS) is a neurological scale that assesses a patient's level of consciousness following a brain injury. A GCS score of 10 indicates a moderate impairment in the client's level of consciousness. Option A) Mild impairment is incorrect because a GCS score of 13-15 is considered mild impairment, not 10. Option C) Severe impairment is also incorrect as GCS scores indicating severe impairment typically fall below 8. Option D) Normal is incorrect because a GCS score of 10 does not indicate a normal level of consciousness. In an educational context, understanding the GCS scoring system is crucial for healthcare professionals, especially in emergency situations like motor vehicle accidents. It helps in quickly assessing and communicating a patient's neurological status, guiding treatment decisions and predicting outcomes. Healthcare providers must accurately interpret GCS scores to provide appropriate care and interventions based on the level of impairment indicated.

Correct Answer: A

Rationale: Diuretics are prescribed to reduce fluid overload in clients with heart failure. By promoting urine output, diuretics help alleviate symptoms like shortness of breath and swelling. Positioning and dietary changes can also be part of the care plan, but administering diuretics is the immediate priority.

Correct Answer: A

Rationale: The correct answer is A) Administer 50% dextrose IV push. In this scenario, the client with type 1 diabetes mellitus is experiencing hypoglycemia with symptoms of confusion and sweating, indicating a severe drop in blood sugar levels. The priority action is to rapidly raise the blood sugar to a safe level to prevent further complications such as seizures, coma, or even death. Administering 50% dextrose IV push provides a quick and direct source of glucose to rapidly increase the blood sugar levels. Option B) Provide a carbohydrate snack is not the priority action in this situation because the client is experiencing severe hypoglycemia, and oral intake may not be effective or fast enough to raise the blood sugar levels to a safe range. Option C) Checking the client's urine for ketones is important in managing diabetes, especially type 1, to assess for diabetic ketoacidosis. However, in this acute situation of hypoglycemia, treating the low blood sugar is the immediate priority. Option D) Starting an insulin drip is contraindicated in a client experiencing hypoglycemia as it will further lower the blood sugar levels, worsening the client's condition. Educationally, this scenario highlights the critical importance of recognizing and promptly treating hypoglycemia in clients with diabetes, particularly type 1. Nurses must be able to assess and manage hypoglycemic episodes effectively to prevent serious complications and ensure client safety. Prioritizing actions based on the client's condition and immediate needs is crucial in emergency situations involving clients with diabetes.

Correct Answer: B

Rationale: In this scenario, the nurse's first action should be to discontinue the antibiotic (option B). This is because the client is exhibiting signs of a potential allergic reaction to the medication, as evidenced by the development of a rash and difficulty breathing. Discontinuing the antibiotic is crucial to prevent further adverse reactions and ensure the client's safety. Administering epinephrine (option A) is not appropriate as the client's symptoms do not indicate an anaphylactic reaction that would warrant the use of epinephrine. Assessing the client's oxygen saturation (option C) is important, but in this case, discontinuing the potentially offending medication takes precedence to address the immediate allergic reaction. Calling the healthcare provider (option D) is important, but not the first action to take when the client is experiencing respiratory distress and a rash. Educationally, this question highlights the importance of recognizing and managing allergic reactions to medications promptly in clinical practice. It emphasizes the need for nurses to prioritize patient safety by taking swift and appropriate actions when faced with signs of adverse drug reactions. Understanding the appropriate steps to take in such situations is crucial for providing high-quality patient care.

Correct Answer: A

Rationale: In caring for a client with an exacerbation of COPD, the most important intervention to promote effective breathing is to encourage diaphragmatic breathing (Option A). Diaphragmatic breathing helps the client maximize the use of their diaphragm, the main muscle of respiration, leading to improved oxygen exchange and ventilation. This technique also reduces the work of breathing and helps the client achieve better oxygen saturation levels. Increasing the client's oxygen flow rate (Option B) may seem beneficial, but it does not address the underlying issue of ineffective breathing mechanics that diaphragmatic breathing targets. Having the client perform range of motion exercises (Option C) and placing them in a supine position (Option D) can actually worsen respiratory distress in COPD by reducing lung expansion and increasing the workload of breathing. In an educational context, understanding the importance of diaphragmatic breathing in COPD management highlights the significance of optimizing respiratory function through evidence-based interventions. By prioritizing this technique, nurses can effectively support clients with COPD in improving their breathing patterns and overall respiratory status, ultimately enhancing patient outcomes and quality of life.