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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The glossopharyngeal nerve is involved in several functions, including taste sensation on the posterior third of the tongue, salivation, and the sensation of the pharynx. It also plays a role in swallowing and gag reflex. However, it is not responsible for the movement of the jaw or clenching of the jaw.
B. The trigeminal nerve is responsible for sensation in the face and also controls the muscles of mastication (chewing). It has both sensory and motor functions. The motor branches of the trigeminal nerve, specifically the mandibular division, innervate the muscles that allow for jaw movement, including clenching.
C. The vagus nerve has a broad range of functions, including regulating heart rate, digestive tract motility, and some aspects of speech and swallowing. It does not control jaw movement or clenching, so it is not relevant to this observation.
D. The facial nerve controls the muscles of facial expression, including movements like smiling, frowning, and closing the eyes. It is not involved in the motor control of the jaw or clenching actions.
Correct Answer is B
Explanation
A. Extinction refers to the phenomenon where a person fails to recognize a stimulus on one side of the body when another stimulus is presented simultaneously on the opposite side. This is often tested in cases of neurological impairment, particularly in the context of sensory neglect or loss
B. Stereognosis is the ability to identify an object by touch and proprioception without visual input. It involves recognizing the shape, size, and texture of an object solely through tactile information. Placing a coin in the patient’s hand and asking them to identify it with their eyes closed tests their ability to use tactile information to recognize objects, making stereognosis the correct term for this assessment.
C. Proprioception is the sense of the position and movement of the body and its parts. It involves awareness of body position in space, which is crucial for coordination and balance. While important, proprioception does not specifically involve identifying objects by touch alone; it is more about the awareness of body position.
D. Two-point discrimination is the ability to distinguish between two closely spaced points of contact on the skin. It tests the sensitivity of the skin to touch and is often used to assess sensory nerve function. It does not involve identifying objects by touch but rather measuring how well one can discern between two separate points of contact.
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