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?

Observe for eye opening to a painful stimulus.

Ask the client to open his eyes.

Notify the healthcare provider.

Check the pupillary response to light.

Answer and Explanation

The Correct Answer is B

A. Observe for eye opening to a painful stimulus: Using a painful stimulus is part of the Glasgow Coma Scale (GCS) assessment for level of consciousness, providing a systematic way to determine the client's response level. This step should follow if the client does not respond to verbal commands.

B. Ask the client to open his eyes: This is a less invasive step that should be attempted first before applying a painful stimulus. It can provide immediate information about the client's level of consciousness and ability to follow commands.

C. Notify the healthcare provider: Notifying the healthcare provider is essential if the client's condition is critical or worsening. However, it should follow after initial assessment steps have been taken to determine the immediate status.

D. Check the pupillary response to light: Checking pupillary response is important for neurological assessment but does not directly address the need to evaluate the client's response to stimuli, which is critical for assessing consciousness levels.

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Correct Answer is A

Explanation

A. "What were you doing when you first noticed the problem?"

This question helps to identify any specific activities or events that may have triggered the onset of back pain. Understanding the circumstances surrounding the pain can provide valuable information about its potential cause.

B. "Have you taken any medications to relieve the pain?"

While it's important to assess if the adolescent has taken any medications, such as over-the-counter pain relievers, to manage the pain, this question may not be the most immediate priority. It's essential to first gather information about the nature and onset of the pain to guide further assessment and management.

C. "Do you remember ever having this type of pain in the past?"

This question helps to determine if the adolescent has a history of similar back pain episodes. Past episodes of back pain can provide insight into potential underlying conditions or recurrent issues that may be contributing to the current complaint.

D. "Does changing your position make the pain worse?"

This question is crucial in assessing the characteristics of the pain and its response to movement or positional changes. It can help differentiate between musculoskeletal causes of back pain, which may worsen with movement, and other potential causes.

A. Multiple yellow lesions with a grainy surface. B. Large, flat, dark red irregular area on the neck. C. Bluish discoloration of the nail beds. D. Multiple silver striae on the abdomen

Correct Answer is C

Explanation

A. Multiple yellow lesions with a grainy surface. These could indicate xanthomas, which are associated with lipid disorders and may warrant further investigation and treatment.

B. Large, flat, dark red irregular area on the neck. This could be a port-wine stain, which is typically a congenital condition and may not require immediate medical intervention unless associated with other symptoms.

C. Bluish discoloration of the nail beds. This indicates cyanosis, which can be a sign of hypoxia or cardiovascular issues. It requires prompt evaluation by a healthcare provider to determine the underlying cause and necessary interventions.

D. Multiple silver striae on the abdomen. Striae, or stretch marks, are usually benign and often result from rapid weight changes or hormonal variations. They typically do not require immediate medical attention.

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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

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Correct Answer is C

Explanation

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