A patient is stuporous but reacts by withdrawing from painful stimuli. Which term is most appropriate for this patient?
Semicomatose
Somnolent
Lethargic
Comatose
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The client should maintain systolic BP between 120 and 129 mm Hg.
This is an appropriate recommendation. The American Heart Association (AHA) guidelines recommend maintaining systolic BP below 130 mm Hg to reduce the risk of stroke and other cardiovascular events in individuals with a history of stroke or TIA.
B. The client should maintain systolic BP between 130 and 135 mm Hg.
This is slightly above the recommended range. While systolic BP below 135 mm Hg is generally recommended for individuals with a history of stroke or TIA, a range of 130-135 mm Hg may still be acceptable based on individual patient factors and risk assessments.
C. The client should maintain systolic BP between 136 and 140 mm Hg.
This is above the recommended range. Systolic BP between 136 and 140 mm Hg may be considered elevated and should be managed to lower levels to reduce the risk of recurrent TIA or stroke.
D. The client should maintain systolic BP between 141 and 145 mm Hg.
This is above the recommended range. Systolic BP above 140 mm Hg is generally considered elevated and should be managed to lower levels to reduce the risk of recurrent TIA or stroke.
Correct Answer is A
Explanation
A. Bradycardia, hypertension, and widening pulse pressure
This combination of symptoms is characteristic of Cushing's triad. Bradycardia (slow heart rate), hypertension (elevated blood pressure), and widening pulse pressure (difference between systolic and diastolic blood pressure) are indicative of increased ICP, specifically resulting in the compression of brain structures that regulate vital functions.
B. Widening pulse pressure, headache, and seizure
While headache and seizure may occur in patients with increased ICP, widening pulse pressure alone is not sufficient to meet the criteria of Cushing's triad. The presence of bradycardia and hypertension, along with widening pulse pressure, is more indicative of Cushing's triad.
C. Hypertension, tachycardia, and headache
Hypertension and headache may occur in patients with increased ICP, but the absence of bradycardia and widening pulse pressure makes this option less characteristic of Cushing's triad.
D. Hypotension, tachycardia, and narrowing pulse pressure
Hypotension (low blood pressure) and narrowing pulse pressure are not typically associated with Cushing's triad. Tachycardia (rapid heart rate) may occur in response to increased ICP, but it is usually accompanied by bradycardia rather than hypotension.

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