In assessing a male client's level of consciousness, the nurse determines that the client does not open his eyes spontaneously. Which should the nurse do next?

Notify the healthcare provider.

Observe for eye opening to a painful stimulus.

Check the pupillary response to light.

Ask the client to open his eyes.

Answer and Explanation

The Correct Answer is B

A.   While notifying the healthcare provider is important if there are significant changes in the client's level of consciousness, it should not be the immediate next step. Before alerting the provider, the nurse needs to perform additional assessments to determine the extent of the client's unresponsiveness and gather more information about their neurological status.
B.   Observing for eye opening in response to a painful stimulus is a critical step in assessing the depth of unconsciousness. This response helps determine the client's level of consciousness and can provide information about the severity of their condition.
C.   Checking the pupillary response to light is important in evaluating neurological function and can provide information about brainstem activity and potential neurological deficits. However, it is secondary to checking for responses to stimuli like painful stimuli if the client is not opening their eyes spontaneously. Pupillary response should be assessed as part of a comprehensive neurological exam.
D.   Asking the client to open his eyes might not be effective if the client is unresponsive or has impaired consciousness. If the client is not responding spontaneously, it is likely that verbal commands will also be ineffective. This step is less useful when assessing levels of consciousness compared to more objective assessments like responses to painful stimuli.

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Correct Answer is A

Explanation

A. A firm mass at the bottom of the left rib cage could indicate an enlarged spleen. Splenomegaly can result from various conditions such as infections, liver disease, or blood disorders. This finding is considered abnormal and warrants further evaluation.
B. Rebound tenderness in the right upper quadrant is used to assess for peritoneal irritation, often associated with conditions such as appendicitis. This finding is not specific to the spleen but rather indicates potential issues in the right side of the abdomen, and is not directly related to palpation of the spleen.
C. The spleen is normally not palpable in most people. If the tip of the spleen is palpable during deep palpation or when the client is asked to exhale forcefully, it may indicate mild splenomegaly. While this finding might suggest an abnormality, it is less alarming than a firm, consistently palpable mass.
D. McBurney’s point is located in the right lower quadrant and is used to assess for appendicitis. Pain at McBurney’s point is related to appendiceal inflammation and is not specific to the spleen. This finding does not provide information about the spleen but rather about potential appendiceal pathology.

A. Musical intermittent sounds. B. Irregular dicks and gurgles. C. High pitched tinkling. D. Longed prolonged

Correct Answer is B

Explanation

A. Musical sounds or high-pitched, tinkling noises are not typically considered normal bowel sounds. These types of sounds might indicate increased bowel activity or bowel obstruction. They are usually associated with abnormal conditions like bowel obstruction or early signs of a bowel problem.
B. This description is consistent with normal bowel sounds. Bowel sounds are usually described as clicks and gurgles that occur irregularly. They are typically heard as a mix of low to moderate pitched sounds and are a normal part of the gastrointestinal activity. Normal bowel sounds usually have an irregular pattern and may vary in frequency and intensity.
C. High-pitched tinkling sounds are not considered normal and could indicate abnormal bowel activity. These sounds are often associated with increased intestinal motility, which can occur in conditions such as bowel obstruction. They suggest that the bowel is more active than normal, which could be a sign of an underlying problem.
D. Prolonged gurgling sounds can sometimes be heard in cases of increased bowel activity but are not typical of normal bowel sounds. Normal bowel sounds are generally intermittent and irregular rather than prolonged. Prolonged gurgles might suggest issues like increased bowel activity or a bowel condition requiring further investigation.

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In assessing a male client's level of consciousness, the nurse determines that the client does not open his eyes spontaneously. Which should the nurse do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse examines a client's abdomen. Which finding indicates an abnormal response when palpating the spleen?

Correct Answer is A

Explanation

The nurse places the diaphragm of a warmed stethoscope on a client's abdomen to auscultate the bowel sounds. Which finding is considered normal?

Correct Answer is B

Explanation

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