The client is a male who states his wife complains that his snoring awakens her at night.
The spouse is present.
To obtain further data, the nurse asks the spouse:

Choice A rationale

The adrenal glands primarily produce hormones that regulate metabolism, immune system, blood pressure, stress response, and other essential functions. While these hormones are crucial for overall bodily function and indirectly influence alertness and arousal, they are not the primary neurological structures responsible for maintaining a conscious and aroused state.

Choice B rationale

The renin-angiotensin-aldosterone system (RAAS) is a hormonal system that regulates blood pressure and fluid balance. While changes in blood pressure and fluid balance can affect overall well-being and indirectly influence alertness, the RAAS is not the neurological center responsible for a person's state of arousal.

Choice C rationale

Cranial nerves are a set of twelve paired nerves that emerge directly from the brain. They are responsible for a wide range of sensory and motor functions, including vision, hearing, taste, smell, facial movements, and swallowing. While some cranial nerves contribute to sensory input that can influence alertness, they are not the central structure responsible for maintaining arousal itself.

Choice D rationale

The reticular activating system (RAS) is a network of neurons located in the brainstem that plays a crucial role in regulating wakefulness, alertness, and the sleep-wake cycle. It filters incoming sensory information and relays important signals to the cerebral cortex, maintaining a state of arousal and consciousness. Damage to the RAS, such as that which can occur following a stroke, can lead to altered levels of consciousness. .

Choice A rationale

Creating a plan of care for a client recovering from a stroke requires comprehensive assessment, synthesis of complex data, and the establishment of nursing diagnoses and interventions. This falls within the scope of practice of a registered nurse who has the education and expertise in complex patient management.

Choice B rationale

Assessing a pressure injury involves observing and documenting wound characteristics. While an RN may perform this, an LVN, under the supervision of an RN, can also contribute to this task by collecting and reporting data about the wound.

Choice C rationale

Providing oral suctioning is a basic nursing skill that can be performed by both RNs and LVNs, following appropriate training and established protocols, to maintain airway patency for a client with pneumonia.

Choice D rationale

Administering internal feedings through a nasogastric tube is a task that can be delegated to an LVN who has received specific training and demonstrated competency, under the supervision of an RN, provided the client is stable and the feeding protocol is well-established.

Choice E rationale

Inserting a urinary catheter can be performed by both RNs and LVNs who have received the necessary education, training, and demonstrated competency in this invasive procedure, according to facility policies and state regulations.