After completing a neurological assessment, the nurse documents that the client is stuporous. Which of the following describes this level of consciousness?
Minimal movement, verbal responses limited to sounds, awakens briefly only with extreme vigorous stimulation.
Extremely drowsy, minimally responsive, limited ability to follow commands, vigorous stimulation needed to waken.
Alert and oriented x3, sluggish, drowsy, wakes to voice or gentle shaking.
Does not respond to verbal stimuli, does not speak, decorticate/decerebrate posturing in response to pain.
The Correct Answer is A
Choice A reason: This is the correct answer because this describes a stupor, which is a state of near-unconsciousness or reduced responsiveness. A stuporous client shows minimal movement and verbal responses and requires extreme vigorous stimulation such as painful stimuli to awaken briefly.
Choice B reason: This is incorrect because this describes obtundation, which is a state of reduced alertness or awareness. An obtunded client is extremely drowsy and minimally responsive and requires vigorous stimulation such as shaking or shouting to wake.
Choice C reason: This is incorrect because this describes lethargy, which is a state of decreased energy or activity. A lethargic client is alert and oriented x3 (to person, place, and time), but sluggish and drowsy, and wakes to voice or gentle shaking.
Choice D reason: This is incorrect because this describes a coma, which is a state of deep unconsciousness or unresponsiveness. A comatose client does not respond to verbal stimuli or speak and shows abnormal posturing in response to pain, such as decorticate (flexion of arms and extension of legs) or decerebrate (extension of arms and legs).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: Measuring the abdominal girth is not related to asterixis, which is a tremor of the hand when the wrist is extended. It may indicate ascites, which is a complication of cirrhosis, but not asterixis.
Choice B Reason: This is the correct choice. Asterixis is a flapping tremor of the hand when the wrist is extended, sometimes said to resemble a bird flapping its wings. It is caused by abnormal function of the diencephalic motor centers that regulate the muscles involved in maintaining posture. It is a sign of hepatic encephalopathy, which is a neuropsychiatric disorder that occurs in patients with liver disease.
Choice C Reason: Having the client flex and extend their foot is not related to asterixis, which affects the hand and wrist. It may test for ankle clonus, which is a rhythmic contraction of the calf muscles when the foot is dorsiflexed. It indicates an upper motor neuron lesion, but not hepatic encephalopathy.
Choice D Reason: Asking the client to walk heel to toe is not related to asterixis, which affects the hand and wrist. It may test for balance and coordination, which can be impaired in patients with hepatic encephalopathy, but it is not a specific sign of asterixis.
Correct Answer is D
Explanation
Choice A reason: Resting in bed for at least 2 days is not necessary after cataract surgery. The client should resume normal activities as soon as possible, but avoid strenuous activities that increase intraocular pressure.
Choice B reason: Deep breathing and coughing four times a day are not related to cataract surgery. This is a technique to prevent respiratory complications after abdominal or thoracic surgery.
Choice C reason: After two days, a creamy discharge is not normal. This could indicate an infection or inflammation of the eye. The client should report any changes in vision, pain, redness, swelling, or discharge to the provider.
Choice D reason: Keeping the head up and straight is the correct instruction. This helps to prevent increased intraocular pressure and bleeding in the eye. The client should also avoid rubbing or touching the eye, wearing sunglasses to protect from bright light, and using prescribed eye drops as directed.
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