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.

Answer and Explanation

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).

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

Explanation

Choice A Reason: Edema is not a specific finding of a systemic infection, but rather a possible sign of fluid overload or impaired venous return. It can occur due to excessive infusion rate, heart failure, or obstruction of blood flow in or around the central line.

Choice B Reason: This is a correct choice. Purulent drainage at intravenous insertion site is a finding of a local infection that can spread systemically. It indicates bacterial invasion and inflammation of the skin and subcutaneous tissue around the catheter.

Choice C Reason: Redness at insertion site is a finding of a local infection that can spread systemically. It indicates increased blood flow and inflammation of the skin and subcutaneous tissue around the catheter.

Choice D Reason: Nausea is not a specific finding of a systemic infection, but rather a possible side effect of parenteral nutrition or a symptom of another condition. It can occur due to electrolyte imbalance, hyperglycemia, or gastrointestinal disorders.

Choice E Reason: This is a correct choice. Leukocytosis is a finding of a systemic infection that indicates increased production and release of white blood cells in response to infection. It can be detected by a blood test.

Choice F Reason: This is a correct choice. Fever is a finding of a systemic infection that indicates increased body temperature due to activation of the immune system and release of pyrogens. It can be measured by a thermometer.

A. Use sign language when communicating with the client. B. Speak loudly and into the client's good ear. C. Speak directly to the client in a normal, clear voice. D. Sit by the client's side and speak very slowly.

Correct Answer is C

Explanation

Choice A reason: This is incorrect because using sign language when communicating with the client is not an appropriate action for the nurse to take. Sign language is a form of communication that uses hand gestures, facial expressions, and body movements. It is not a universal language and requires training and practice. The nurse should not assume that the client knows or prefers sign language unless they have indicated so.

Choice B reason: This is incorrect because speaking loudly and into the client's good ear is not an appropriate action for the nurse to take. Speaking loudly can distort the sound quality and cause discomfort or irritation to the client. Speaking into the client's good ear can also create a sense of imbalance and isolation. The nurse should speak at a normal volume and tone, and face the client directly.

Choice C reason: This is the correct answer because speaking directly to the client in a normal, clear voice is an appropriate action for the nurse to take. Speaking directly to the client can help them see the nurse's mouth movements and facial expressions, which can enhance understanding and communication. Speaking in a normal, clear voice can help convey the message clearly and respectfully.

Choice D reason: This is incorrect because sitting by the client's side and speaking very slowly is not an appropriate action for the nurse to take. Sitting by the client's side can make it difficult for them to see the nurse's face and hear their voice. Speaking very slowly can also make the message unclear and patronizing. The nurse should sit in front of the client and speak at a normal pace.

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After completing a neurological assessment, the nurse documents that the client is stuporous. Which of the following describes this level of consciousness?

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

Explanation

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Correct Answer is C

Explanation

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