Level of Consciousness
A client who has sustained a head injury is being evaluated in the emergency room. The nurse performs a neurological assessment and notes that the client is somnolent. Which of the following describes an somnolent client response? Select all that apply. Falls asleep between stimulation Needs stimulation to follow commands Alert and following commands Does not respond at all Difficult to arouse
Falls asleep between stimulation Needs stimulation to follow commands Difficult to arouse A client who is somnolent is difficult to arouse and has trouble staying awake and following commands. This type of response may be seen in some types of head injuries.
A nurse is caring for a client who has experienced a head injury. The nurse is performing a focused neurological exam and documents that the client's mental status is obtunded. Which best describes a client's affect as obtunded? The client is easily awakened with voice from normal sleep The client does not respond to any stimulation The client only arouses to painful stimuli The client has very slow responses and decrease interest in the environment
The client has very slow responses and decrease interest in the environment Following a head injury, a nurse may perform a neurological exam that assesses the client's mental status. Several terms are used to describe the client's level of consciousness. When a nurse describes a client's mental status as obtunded, it means that the client is difficult to arouse, has very slow responses, and excessive sleepiness.
The nurse recognizes that the client is suffering from acute delirium. What is the first action the nurse should take? Increase client checks to every two hours until it resolves Recognize that this represents an exacerbation of the client's underlying dementia Document the findings at the end of the shift Contact the provider because this is considered a medical emergency
Contact the provider because this is considered a medical emergency Delirium is considered to be a medical emergency because it is a sign that there is an acute illness or disease process occurring that has lead to the condition. Older clients diagnosed with delirium are at an increased risk for mortality during the 12 months following hospital admission, and delirium is an independent risk factor of increased mortality. The provider should be notified as soon as possible.
A client who has suffered a head injury is brought in to the emergency department. The nurse assesses the client's level of consciousness by first checking for alertness and orientation. What is the most appropriate question for the nurse to ask in order to assess if the client is alert and oriented? Do you know where you are right now? What month is it? Did anyone come in with you? Are you having any pain?
What month is it? To assess a client's level of consciousness, the nurse should ask the client their name, the time or date, and where they are. The nurse should avoid yes or no questions and instead focus on those that require a short answer. This question may be frustrating, but it is important to evaluate the type of question being asked (using questions that require more than yes or no).
A unconscious client is brought into the trauma bay after being "found down" in the community. There is no reportable history and no witnesses to any events leading up to the client being found. All except which of the following diagnostic tests would be appropriate for this client while in the trauma bay? MRI of the brain Finger stick for blood sugar ETOH level CT Scan of the brain
MRI of the brain This is the incorrect diagnostic tool for this client making it the correct answer. This is not a diagnostic test usually performed while in the trauma bay. While is may be diagnostically significant, the MRI is a much longer test than the CT scan and is usually done after other, faster diagnostic exams have proved inconclusive. A CT scan will give quick results that are needed for prompt treatment of this client.
The nurse is assigned to an older adult client in the emergency department whose family members report she is "acting bizarre". The nurse notes a decreasing level of consciousness and confusion. The nurse obtains vital signs which are within normal limits. What is the nurse's next priority? Obtain a urine sample Ask the client if she knows where she is Obtain an EKG Obtain a POC glucose
Obtain a POC glucose Any client with altered mental status should be checked for hypoglycemia, because hypoglycemia can quickly deteriorate into an emergent situation as the glucose level drops and the client moves toward unresponsiveness.
A client is brought to the trauma bay after a motor vehicle collision with rollover. The client is unconscious but breathing. On the neurological assessment, the client does not respond to his/her name. The nurse performs a sternal rub and the client's eyes open, arms flex in no particular direction, and the client mumbles incoherently. The nurse anticipates the next action to be which of the following? Prepare for rapid sequence intubation Move on to your secondary survey Facilitate family presence Administer normal saline through 2 large bore IV's
Prepare for rapid sequence intubation The client is exhibiting a diminished Glasgow coma score (Eye-opening to painful stimulation = 2, Withdrawal to painful stimulation = 4, incomprehensible sounds = 2, Total score = 8) A GCS of 8 is usually an indicator of an acute decrease in level of consciousness and intubation is recommended to protect the client's airway. GCS 8=intubate.
A client has been diagnosed with REM sleep behavior disorder. Which of the following is associated with this type of sleep disorder? Select all that apply. The client often needs psychotherapy and counseling for treatment The client may be dangerous toward their bed partner The client may get up out of bed and act out activities The client usually suffers from restless leg syndrome The client may be aggressive and violent while asleep
The client may be dangerous toward their bed partner The client may get up out of bed and act out activities The client may be aggressive and violent while asleep REM sleep behavior disorder describes a type of sleep disorder in which a client may get up out of bed while still asleep and act out dreams. The client may become aggressive or even violent during an episode. The condition is often diagnosed after a bed partner notices the behavior.
A nurse is helping a client to develop a sleep hygiene program to improve sleep habits. Which of the following would the nurse suggest for this client as part of sleep hygiene? Select all that apply. The client should go to bed later than usual The client should try to find a comfortable position for sleeping The client should try to wake up at an earlier time than usual The client may sleep better if another person is in the room The client should develop a familiar nighttime routine
The client should develop a familiar nighttime routine The client should try to find a comfortable position for sleeping Sleep hygiene is the process of developing practices that will best promote sleep for the client. The nurse can counsel the client about better sleep hygiene by suggesting that they keep the same schedule for sleeping and waking up, avoiding caffeine and alcohol near bedtime, and finding a comfortable position for sleep. The nurse can counsel the client about better sleep hygiene by suggesting that they keep a familiar evening routine.
A client is dying and has become unconscious but is still breathing. While standing next to the client's bed, his sister says, "I always wanted to tell him that I loved him, but it was so hard for me. Now it is too late." Which response of the nurse is most appropriate? You can still tell him. Hearing is the last sense to go so he may hear you He probably already knows Next time don't wait. Tell the person when you have the chance We should talk about this somewhere else and not at the bedside
You can still tell him. Hearing is the last sense to go so he may hear you A client who is dying and has become unconscious may still be able to hear what is going on. Studies have shown that hearing is the last sense to go when a person dies. The nurse should not make the client's family member feel guilty about her feelings, but should instead encourage her to communicate.
