A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and temperature 36.8° C (98.2° F). Which of the following actions should the nurse perform?

Hold the client's evening dose of digoxin.

Increase the client's fluid intake.

Complete a neurological check.

Administer the prescribed PRN antihypertensive medication.

Answer and Explanation

The Correct Answer is C

A.   Holding the client's evening dose of digoxin is not the priority at this time. The client's symptoms of confusion and drowsiness require immediate attention to determine the cause.
B.   Increasing the client's fluid intake may be important for various reasons, but it is not the most urgent action in this situation. The client's altered mental status and vital signs need to be assessed first.
C.   Completing a neurological check is the most appropriate action in this situation. The sudden onset of confusion and drowsiness may indicate a neurological issue that needs to be assessed promptly. This includes assessing the client's level of consciousness, pupillary response, motor function, and other neurological signs.
D.   Administering the prescribed PRN antihypertensive medication is not indicated based on the client's current presentation. The client's symptoms are more suggestive of a neurological issue rather than hypertension. It's important to address the altered mental status first.

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 ["B","C","E"]

Explanation

A. Washing the client's extremities from proximal to distal is a good practice, but it is not specifically related to caring for an immobile client.
B. Checking for personal items when changing the bed linens is important to ensure that the client's belongings are not lost or misplaced during the process.
C. Shaving the client's hair in the direction of hair growth helps prevent skin irritation and ingrown hairs.
D. The gown should be placed on the weaker arm first.
E. This is an appropriate temperature that can help client remain comfortable.

A. Checking the pupillary response to light B. Eliciting the gag reflex C. Testing visual acuity D. Observing for facial symmetry

Correct Answer is A

Explanation

A. Cranial nerve III, also known as the oculomotor nerve, controls the muscles that move the eye and regulates the size of the pupil. Assessing the pupillary response to light helps evaluate the function of this nerve.
B. Eliciting the gag reflex is associated with cranial nerves IX (glossopharyngeal) and X (vagus), not cranial nerve III.
C. Testing visual acuity is primarily associated with cranial nerve II (optic nerve), not cranial nerve III.
D. Observing facial symmetry is important for assessing cranial nerve VII (facial nerve), not cranial nerve III.

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 nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and temperature 36.8° C (98.2° F). Which of the following actions should the nurse perform?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing hygiene care for a client who is immobile. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

Correct Answer is A

Explanation

A nurse is caring for a client who is scheduled for an elective surgical procedure. Which of the following actions should the nurse take regarding informed consent?

When reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. Which of the following actions should the nurse take?

A nurse is caring for a client who is prescribed bedrest. The plan of care indicates that the client should perform isometric exercises every 2 hr. Which of the following actions should the nurse take as directed by the plan of care?

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take?

A nurse in a clinic is interviewing a client who will undergo diagnostic testing The nurse should ask about a client's potential allerges during which phase of the nursing process?