A client opens the eyes and answers questions however falls back asleep within seconds. How should the nurse document this assessment finding?

Coma

Lethargy

Obtunded

Stupor

Answer and Explanation

The Correct Answer is B

A.   Coma is a state of profound unconsciousness where the patient cannot be awakened and does not respond to any stimuli, including verbal commands or physical stimuli.

B.   Lethargy is characterized by a state of drowsiness or fatigue where the patient may fall asleep easily but can be roused to respond appropriately when stimulated. The patient shows decreased alertness but is still capable of engaging with stimuli.
C.   Obtunded refers to a state where the patient has reduced alertness and responsiveness. They may respond slowly and require increased stimulation to achieve a response. They are less aware of their environment and have dulled senses.
D.   Stupor is a state of near-unconsciousness where the patient can only be awakened by vigorous or painful stimuli. They may not respond to verbal commands but may show some response to more intense stimuli.

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Correct Answer is A

Explanation

A. Flight of ideas is characterized by a rapid and continuous flow of thoughts where the individual frequently shifts topics, often making it difficult to follow their conversation. This is commonly observed in conditions like mania or hypomania, often seen in bipolar disorder.
B. Confabulation involves fabricating or inventing stories or information to fill in gaps in memory. It is often seen in conditions affecting memory or cognition, such as Korsakoff’s syndrome or certain types of dementia.
C. Depression typically involves symptoms such as low mood, decreased energy, and lack of interest in activities, rather than rapid speech or topic shifts. The client’s accelerated pace of speech and jumping from topic to topic do not align with the characteristics of depression.
D. Schizophrenia is a broad term for a range of symptoms, including hallucinations, delusions, disorganized thinking, and impaired social functioning. While disorganized thinking can be a symptom of schizophrenia, the specific behavior described (accelerated speech and jumping topics) more specifically indicates flight of ideas, which is not exclusive to schizophrenia.

A. Coma B. Stupor C. Lethargy D. Obtunded

Correct Answer is D

Explanation

A. Coma is a state of profound unconsciousness where the patient cannot be awakened and does not respond to any external stimuli. The patient is completely unresponsive, with no eye opening or verbal responses.
B. Stupor is a state where the patient is almost completely unresponsive and can only be awakened by vigorous or painful stimuli. When aroused, they may only give brief, non-purposeful responses.
C. Lethargy is characterized by drowsiness and decreased alertness. The patient may fall asleep easily but can be awakened and will respond appropriately to stimuli. They might appear sluggish or tired.
D. Obtunded refers to a state where the patient has a reduced level of consciousness and responsiveness. They may be difficult to arouse, respond slowly to stimuli, and have a dulled sense of awareness. They need increased stimulation to achieve a response.

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A client opens the eyes and answers questions however falls back asleep within seconds. How should the nurse document this assessment finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is admitting a client to the unit for surgery the next morning. The nurse notes that the client speaks at an accelerated pace and jumps from topic to topic no of which progresses to sensible conversation. What would the nurse document about this client?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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