NACE Physiological Adaptation 3

Question 1

A patient with a traumatic brain injury has a Glasgow Coma Scale (GCS) score of 6. What does this indicate about the patient's neurological status?

Accepted Answer

Severe brain injury

Answer

Normal neurological function

Answer

Mild brain injury

Answer

Moderate brain injury

Question 2

A patient with COPD is receiving oxygen therapy. The nurse notes the oxygen saturation is 96%. What is the nurse's priority concern?

Accepted Answer

The saturation may be too high, potentially suppressing the hypoxic drive

Answer

The saturation is too low and oxygen should be increased

Answer

This is an expected finding requiring no action

Answer

The pulse oximeter must be malfunctioning

Question 3

A nurse is caring for a patient experiencing status epilepticus. Which intervention takes priority?

Accepted Answer

Maintaining a patent airway and administering IV benzodiazepine

Answer

Placing a padded tongue blade in the mouth

Answer

Restraining the patient's extremities to prevent injury

Answer

Obtaining a detailed neurological history from family members

Question 4

A patient presents with sudden severe headache described as 'the worst headache of my life.' Which condition should the nurse suspect?

Accepted Answer

Subarachnoid hemorrhage

Answer

Migraine headache

Answer

Tension headache

Answer

Cluster headache

Question 5

A patient with acute pancreatitis reports severe abdominal pain. Which position should the nurse help the patient assume for pain relief?

Accepted Answer

Side-lying fetal position with knees drawn to the chest

Answer

Supine with legs extended

Answer

Right lateral with knees slightly bent

Answer

Prone position with a pillow under the abdomen

Question 6

A nurse is monitoring a patient after a thyroidectomy. Which complication should the nurse assess for within the first 24 hours?

Accepted Answer

Hypocalcemia

Answer

Thyroid storm

Answer

Myxedema coma

Answer

Graves' disease recurrence