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 D

Explanation

A. Observing the chest and upper neck for a rash is not directly relevant to assessing tinnitus. Tinnitus is an auditory condition, and a rash in these areas would not typically provide information about the presence or effects of tinnitus. This option is not suitable for evaluating tinnitus.
B. Evaluating for a loss of peripheral vision is related to visual assessments rather than auditory conditions. Peripheral vision loss does not provide direct information about tinnitus or its effects. This option is not relevant to assessing the impact of tinnitus.
C. Assessing deep tendon reflexes is a neurological examination that helps evaluate the functioning of the nervous system but does not provide information about tinnitus. Tinnitus is related to auditory perception and not directly assessed through reflexes.
D. Performing a hearing test is directly relevant to evaluating tinnitus. Tinnitus often accompanies hearing loss or auditory dysfunction. A hearing test can help determine if there is a hearing impairment or other auditory issues associated with tinnitus.

A. "Can you recall the date the Twin Towers in New York were destroyed?" B. "What is the difference between a hamster and a rabbit as a pet?" C. "Should someone who lives in a glass house throw stones?" D. "Do you write checks if you know the bank account is overdrawn?"

Correct Answer is C

Explanation

A. This question assesses a client's recent memory, not their judgment.
B. This question assesses a client's knowledge and understanding of animals, not their judgment.
C. This question evaluates a client's judgment by assessing their ability to make sound decisions based on hypothetical situations. It requires the client to consider potential consequences and make a logical inference.
D. This question assesses a client's financial knowledge and decision-making skills, but it doesn't directly evaluate their judgment in a hypothetical situation.

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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

In reading a client's record, the nurse notes that the client is experiencing tinnitus. Which assessment provides the nurse with the information needed to evaluate the effects of this condition?

Correct Answer is D

Explanation

While performing a mental status examination, which question should the nurse ask when attempting to evaluate a client's judgment?

Correct Answer is C

Explanation

A client is concerned about developing carpal tunnel syndrome. Which screening technique should the nurse perform to provide the client with useful information?

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When assessing a client's level of consciousness, the nurse determines that the client is alert and ambulatory, but confused. Which follow- up assessment should the nurse complete next?

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