Assessment of the client reveals that he is unresponsive to all stimuli and his eyes remain closed. The nurse documents the client's level of consciousness as which of the following?

Obtunded

Stupor

Coma

Lethargy

Answer and Explanation

The Correct Answer is C

A. Obtunded: Obtunded describes a state where a person has reduced alertness and is difficult to arouse but can respond to stimuli, such as verbal commands or physical touch. The client’s eyes remain closed and they are unresponsive to all stimuli, which is more severe than obtunded.
B. Stupor: Stupor is a condition where a person is in a near-unconscious state and responds only to vigorous or painful stimuli. Although the client is unresponsive to all stimuli, stupor usually involves some minimal response to pain or other strong stimuli, which doesn’t match the complete unresponsiveness described.
C. Coma: A coma is a profound state of unconsciousness where a person is unresponsive to all stimuli, including verbal, visual, and painful stimuli, and their eyes remain closed. This description matches the client’s condition of being unresponsive and with closed eyes.
D. Lethargy: Lethargy is characterized by excessive drowsiness or a reduced level of consciousness where the individual can be aroused with minimal effort. This state does not accurately describe a client who is unresponsive to all stimuli and whose eyes remain closed.

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Correct Answer is A

Explanation

A) This is an abnormal breath sound due to bronchial airways being narrowed, bronchoconstriction: Wheezing is an abnormal breath sound characterized by a high-pitched whistling noise produced during breathing. It occurs when the bronchial airways are narrowed due to bronchoconstriction, inflammation, or mucus, common in conditions like asthma. This narrowing of the airways creates turbulent airflow, leading to the wheezing sound.

B) This is a normal breath sound due to normal gas exchange: Wheezing is not a normal breath sound and is indicative of an obstruction or narrowing in the airways. Normal breath sounds, such as vesicular breath sounds, are smooth and do not include wheezing.

C) This is an abnormal breath sound due to bronchial airways being dilated, bronchodilation: Wheezing results from airway narrowing, not dilation. Bronchodilation, which is the widening of the airways, would typically reduce or resolve wheezing rather than cause it.

D) This is a normal breath sound due to the alveoli being fluid-filled: Wheezing is related to airway narrowing rather than fluid in the alveoli. Fluid in the alveoli would more commonly cause crackles or rales, not wheezing.

A. Flatness B. Dullness C. Resonance D. Hyperresonance

Correct Answer is D

Explanation

A. Flatness: This percussion note is typically associated with areas of high density, such as over muscle or a solid organ like the liver. In a pneumothorax, the lung tissue is not solidified, so flatness is not expected.
B. Dullness: Dullness is generally noted over fluid-filled areas or solid structures, such as a pleural effusion or a mass. In the case of a pneumothorax, where there is air in the pleural space, dullness would not be the expected finding.
C. Resonance: Resonance is the normal percussion note over healthy lung tissue. It indicates normal air-filled lung spaces. In a pneumothorax, the increased air in the pleural space causes an abnormal note.
D. Hyperresonance: This percussion note is associated with increased air in the pleural space, as seen in conditions like a pneumothorax. The extra air causes a more resonant, hollow sound when percussed, distinguishing it from normal lung resonance.

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Assessment of the client reveals that he is unresponsive to all stimuli and his eyes remain closed. The nurse documents the client's level of consciousness as which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nursing student asked the respiratory floor nurse why the adventitious wheezing breath sounds are present in asthmatic patients. The nurse should respond:

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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