The nurse receives a report at the beginning of the shift and learns that the client scores 7 on the Glasgow Coma Scale. The nurse realizes that this client is at which of the following levels of consciousness?

Correct Answer: A

Rationale: A Glasgow Coma Scale score of 7 indicates coma minimal responsiveness below 8. Higher scores denote disability or alertness. Nurses assess this for neurological status.

Correct Answer: A

Rationale: Believing smoking causes cancer and quitting is health belief model (A) belief drives behavior, per HBM. Risk factor (B) is smoking, illness behavior (C) sick response, wellness (D) state. A fits belief-action link, making it correct.

Correct Answer: D

Rationale: Elderly clients' pain reports should be taken seriously (D), per geriatric care pain isn't less felt (A), narcotics aren't barred (B), and it's not normal aging (C). Sensitivity may drop, but pain remains significant; under-treatment risks exist. D ensures proper management, making it the true statement.

Correct Answer: D

Rationale: Implementing fall prevention measures is critical for an immobile patient's safety, involving tools like bed alarms, low beds, or assistance during transfers to mitigate risks in a controlled environment. Immobile patients can't walk independently, so promoting frequent movement isn't feasible and could increase danger. Physical or soft restraints, while sometimes considered, are last-resort options due to ethical and safety concerns, not primary safety strategies. Fall prevention directly addresses the vulnerability of those unable to reposition themselves, reducing injury risk a key nursing responsibility. This approach ensures a safe setting, balancing protection with patient dignity, and aligns with evidence-based practice to minimize harm in immobile populations.

Correct Answer: A

Rationale: Right to refuse is patient rights (A) legal/ethical entitlement, per bill of rights. Moral distress (B) nurse conflict, policy (C) rules, informatics (D) tech not rights-specific. A fits Mr. Gary's autonomy, a core patient right, making it correct.

Correct Answer: A

Rationale: Hyperpyrexia is a temperature above 40°C (104°F) e.g., in severe infections beyond normal fever (38-39°C). Lower thresholds (39°C, 100°F) or extreme (105.8°F) don't define it. Nurses recognize this critical level, triggering urgent cooling measures to prevent organ damage, per emergency protocols.

Correct Answer: C

Rationale: In an urgent case study scenario, the nurse must prioritize orders based on patient stability and immediate needs. Administering 0.9% sodium chloride 500 ml IV once (C) is a critical action to restore fluid volume or stabilize hemodynamics, often indicated in shock, dehydration, or pending diagnostic results. Inserting an indwelling urinary catheter (A) monitors output but isn't immediately life-saving unless bladder obstruction is suspected. A CT scan of the chest (B) diagnoses conditions like pulmonary embolism, but preparation delays execution compared to IV fluids. Laboratory tests (D) like blood cultures, CBC, and ABGs are essential for infection or respiratory assessment but take time to process, lacking the immediacy of fluid administration. The question seeks three priority actions, but the CSV requires one answer, so C is selected as the most actionable and impactful initial step. Rationale: IV saline addresses acute hypovolemia or hypotension swiftly, buying time for diagnostics and interventions, aligning with emergency nursing principles of stabilizing ABCs (airway, breathing, circulation) first.

Correct Answer: B

Rationale: Maslow's hierarchy (1940s) crowns self-actualization realizing potential as mental health's essence e.g., a nurse finding purpose in care. Self-awareness (base), esteem (confidence), and worth (value) build to it. Nursing promotes this peak e.g., meaningful recovery aligning with psychological well-being goals.

Correct Answer: B

Rationale: Ethics guides moral decisions (B), per nursing e.g., right/wrong in care. Not just laws (A), involves care (C), not all (D) moral framework. B truly defines ethics' role, making it correct.