A patient is stuporous but reacts by withdrawing from painful stimuli. Which term is most appropriate for this patient?

Semicomatose

Somnolent

Lethargic

Comatose

Answer and Explanation

The Correct Answer is C

A. Semicomatose:

This term suggests a state between consciousness and coma. A patient who is semicomatose may exhibit some level of responsiveness but is typically unresponsive or only responds to intense stimuli.

B. Somnolent:

Somnolence refers to a state of drowsiness or sleepiness. A somnolent patient may appear sleepy, have difficulty staying awake, and may be slow to respond to stimuli. However, the withdrawal from painful stimuli described in the scenario suggests a higher level of responsiveness than what would typically be expected in a somnolent state.

C. Lethargic:

Lethargy describes a state of reduced alertness or responsiveness. A lethargic patient may appear drowsy, sluggish, and have diminished responses to stimuli. The description of the patient as stuporous (having a decreased level of consciousness) but still reacting by withdrawing from painful stimuli aligns with the characteristics of lethargy.

D. Comatose:

Coma refers to a state of profound unconsciousness where the patient is unresponsive to all stimuli, including painful stimuli. A comatose patient does not demonstrate any purposeful movement or response to stimuli. Since the patient in the scenario exhibits some response to painful stimuli by withdrawing, they do not meet the criteria for being comatose.

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Correct Answer is B

Explanation

A. Insert a padded tongue blade into the client's mouth.

This intervention is not recommended. Placing any object, including a padded tongue blade, into the mouth of someone experiencing a seizure poses a risk of injury, such as biting the tongue or breaking teeth. It can also obstruct the airway and increase the risk of aspiration. Therefore, inserting anything into the client's mouth during a seizure is contraindicated.

B. Place a pillow under the client's head.

Placing a pillow under the client's head can help prevent head injury by providing cushioning and support. It can also help maintain the client's airway and reduce the risk of aspiration. Therefore, this intervention is appropriate and helps ensure the client's safety during the seizure.

C. Gently restrain the client's extremities.

Restraining the client's extremities is not recommended during a seizure. It can increase the risk of injury, such as fractures or dislocations, and may exacerbate muscle contractions. It's important to allow the client's movements to occur naturally while taking measures to ensure their safety, such as removing nearby objects and providing a safe environment.

D. Keep the client in a supine position.

It is essential to ensure that the client's head is turned to the side (recovery position) to prevent aspiration and allow for drainage of oral secretions. Additionally, the nurse should remove any nearby objects that could pose a risk of injury during the seizure.

A. "Have you had an MMR immunization?" B. "Have you had a recent upper respiratory infection?" C. "Have you traveled overseas recently?" D. "Are you taking a multivitamin?"

Correct Answer is B

Explanation

A. "Have you had an MMR immunization?"

This question is not directly relevant to the assessment of Guillain-Barré syndrome. MMR immunization history may be pertinent to other health assessments, such as immunity to measles, mumps, and rubella.

B. "Have you had a recent upper respiratory infection?"

This is the correct answer. GBS often occurs after a recent upper respiratory or gastrointestinal infection, so asking about recent illnesses can provide valuable information for diagnosis.

C. "Have you traveled overseas recently?"

While travel history may be relevant to certain infectious diseases, it is not typically associated with the development of Guillain-Barré syndrome. Therefore, this question is less pertinent in this context.

D. "Are you taking a multivitamin?"

The use of multivitamins is unlikely to be directly related to the development of Guillain-Barré syndrome. While nutritional status is important for overall health, it is not a primary focus when assessing for GBS.

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A patient is stuporous but reacts by withdrawing from painful stimuli. Which term is most appropriate for this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse enters a client's room and finds the client on the floor in the clonic phase of a tonic-clonic seizure. Which of the following interventions should the nurse take?

Correct Answer is B

Explanation

A nurse is collecting data from a client who has a possible medical diagnosis of Guillain-Barré syndrome (GBS). Which of the following questions should the nurse ask the client?

Correct Answer is B

Explanation

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