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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. muscle strength grade of 3 indicates that the client can move the arm (or other limb) against gravity but not against any additional resistance. In this case, if the client is able to actively move the right arm against gravity, this is a correct grading. The ability to move the arm against gravity alone aligns with a grade of 3.
B. A muscle strength grade of 2 indicates that the client can move the arm (or other limb) only with gravity eliminated. This means that the client can move the limb when it is placed in a horizontal position but not against gravity. Since the client can move the arm against gravity, this grade is not applicable.
C. A muscle strength grade of 1 indicates that there is muscle contraction but no movement of the limb. This means there is some visible muscle activity but insufficient to cause any joint movement. Since the client is able to move the arm actively against gravity, this grade does not fit the observed finding.

D. A muscle strength grade of 5 indicates normal strength, where the client can move the limb against gravity and against full resistance. If the client can move the right arm against gravity but not necessarily against full resistance, this is not indicative of a grade of 5. The grade of 5 would be reserved for when the muscle can move against full resistance without difficulty.

A. Maintaining a body weight appropriate to height and frame B. importance of regular exercise C. Maintaining a safe home environment D. Using proper body mechanics with lifting objects E. Outing intake of dairy products

Correct Answer is ["A","B","C","D"]

Explanation

A. Maintaining an appropriate body weight helps reduce the strain on the musculoskeletal system, including joints and muscles. Excess weight can increase the risk of injuries, especially to weight-bearing joints like the knees and hips.
B. Regular exercise helps to strengthen muscles, improve flexibility, and maintain healthy joints. It also promotes overall physical fitness, which can prevent injuries by improving body mechanics and resilience.
C. A safe home environment can help prevent falls and accidents that could lead to musculoskeletal injuries. This includes ensuring that walkways are clear, using non-slip mats, and having proper lighting.
D. Using proper body mechanics involves techniques such as bending the knees, keeping the back straight, and lifting with the legs rather than the back. This helps prevent strain and injuries when lifting heavy objects.
E. Dairy products are a source of calcium and vitamin D, which are important for bone health. Reducing dairy intake could impact bone density if not compensated by other sources of calcium and vitamin D.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A client is able to actively move the right arm against gravity. How should the nurse document this finding using the muscle strength grading?

Correct Answer is A

Explanation

A community health nurse is providing education to help reduce musculoskeletal injuries in adults. What should the nurse include in these instructions? Select all that apply

Correct Answer is ["A","B","C","D"]

Explanation

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

Which are the 3 areas included in the Glasgow Coma Scale to assess levels of consciousness? Select all that Apply.

A 75-year-old male patient who recently started playing Tennis at the local adult care center is complaining of elbow pain associated with extension and flexion range of movement. The nurse knows the likely cause of this patient discomfort is due to:

During an assessment of the cranial nerves, a client reports spontaneously losing balance. The nurse should focus additional assessment on which cranial nerve?

In the Neuro ICU, a comatose patient has this posture in bed: Upper arms are flexed tight to the sides with elbows, wrists, and fingers flexed. The legs are extended and internally rotated. The nurse interprets this posture as:

A patient is able to move both upper arms as follows: active movement against gravity, and some resistance. The nurse should document the muscle strength of the upper arms as:

In the Neuro ICU (intensive care unit) while performing a neurological assessment of the patient the nurse noticed the patient: patient opens eyes, looks at you, responds slowly, and is somewhat confused. What level of consciousness (LOC) is this patient presenting?