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

A GCS score of 3-8 indicates severe brain injury. The patient likely requires intubation and intensive neurological monitoring.

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

COPD patients rely on hypoxic drive for respiratory stimulation. Target SpO2 for COPD patients is typically 88-92%. An SpO2 of 96% may indicate excessive oxygen administration.

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

Status epilepticus is a medical emergency requiring immediate airway management and IV benzodiazepine (typically lorazepam) to terminate the continuous seizure activity.

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

A sudden, severe 'thunderclap' headache described as the worst of the patient's life is the hallmark presentation of subarachnoid hemorrhage until proven otherwise.

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

The fetal position with knees drawn to the chest reduces tension on the abdominal muscles and takes pressure off the inflamed pancreas, providing some pain relief.

Nursing Acceleration Challenge Exam (NACE) I PN-RN Practice Test

Nursing Acceleration Challenge Exam (NACE) I PN-RN Practice Test

NACE Physiological Adaptation 3