In assessing a client's level of consciousness, what should the nurse assess first?

Motor responses.

Eye opening.

Verbal response

Level of alertness.

Answer and Explanation

The Correct Answer is D

a. "Motor responses." Motor responses are important in assessing neurological function, but they are typically assessed after determining the client's overall level of consciousness and alertness. Motor responses are usually assessed when the client is unresponsive or has altered consciousness.

b. "Eye opening." Eye opening is part of the Glasgow Coma Scale (GCS) and is an important indicator of neurological function. However, it is generally assessed after determining the client's level of alertness.

c. "Verbal response." Verbal response is another component of the GCS, assessing how the client responds to verbal stimuli. This assessment also follows the initial determination of the client’s alertness.

d. "Level of alertness." The level of alertness is the first and most fundamental aspect to assess because it gives the nurse a baseline understanding of how aware the client is of their surroundings. This assessment sets the stage for further evaluation of motor, eye, and verbal responses. It helps determine the client's ability to interact and respond to stimuli, guiding subsequent assessments.

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Correct Answer is D

Explanation

Choice A Reason:
Normal mental status for age is incorrect. This choice would not be the most accurate conclusion based on the client's response. While it's possible that the client's response could be influenced by factors such as cultural background or personal interpretation, the inability to understand the metaphorical meaning of a commonly known proverb might suggest some level of cognitive impairment or difficulty with abstract thinking. Therefore, it would be premature to conclude that the client's response reflects a normal mental status for her age.
Choice B Reason:
Impaired concentration is incorrect. Impaired concentration would manifest as difficulty maintaining focus our attention during the interaction. However, the client's response doesn't suggest a lack of attention or focus. Instead, it indicates a misinterpretation of the proverb, which is more indicative of impaired thinking or difficulty understanding abstract concepts rather than impaired concentration.
Choice C Reason:
Impaired memory is incorrect. Impaired memory would typically involve difficulty recalling information or events from the past. In this scenario, the client is able to recall the phrase "Glass Houses" but demonstrates difficulty understanding its meaning. Therefore, impaired memory is not the most appropriate conclusion based on the client's response. Instead, the response suggests impaired thinking or difficulty with abstract reasoning.
Choice D Reason:
Impaired thinking is correct. The client's response indicates difficulty understanding the metaphorical meaning of the proverb "Glass Houses," which typically implies that those who live in fragile or vulnerable situations should avoid criticizing others, as they themselves are also vulnerable to criticism or judgment. Instead, the client's response focuses on the literal interpretation of the phrase, suggesting impaired thinking or difficulty grasping abstract concepts.

A. Excoriation. B. Papules. C. Wheals. D. Fissuring.

Correct Answer is C

Explanation

Choice A Reason:
Excoriation is incorrect. Excoriation refers to scratch marks or abrasions on the skin caused by scratching or rubbing. While excoriation can occur as a result of scratching due to itching caused by an allergic reaction, it is not a specific characteristic of an allergic reaction to an insect bite. However, it may develop secondary to the itching associated with insect bites.
Choice B Reason:
Papules are incorrect. Papules are small, raised bumps on the skin that can have various causes, including insect bites. While papules can sometimes accompany an allergic reaction to insect bites, they are not as characteristic as wheals (hives) in such reactions. Papules may also represent other skin conditions or reactions, so they are not as specific to allergic reactions as wheals.
Choice C Reason:
Wheals are correct. Wheals, also known as hives or urticaria, are raised, red, itchy areas of the skin that often occur as part of an allergic reaction to insect bites, medications, foods, or other allergens. Wheals are typically transient and can vary in size and shape. Excoriation (choice A) refers to scratch marks or abrasions on the skin caused by scratching or rubbing.
Choice D Reason:
Fissuring is incorrect. Fissuring refers to deep cracks or splits in the skin's surface. Fissures are not typically associated with allergic reactions to insect bites. Instead, they may occur in conditions such as eczema, psoriasis, or severe dry skin. Therefore, while skin fissuring may occur in some skin conditions, it is not a typical finding in allergic reactions to insect bites.

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In assessing a client's level of consciousness, what should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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