The nurse is caring for a client who suffered a stroke 3 days ago and is assessing the client's state of arousal.
The nurse knows that the part of the body responsible for a person being alert or aroused is the
adrenal glands.
renin-angiotensin-aldosterone system.
cranial nerves.
reticular activating system.
The Correct Answer is D
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. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While reporting communicable diseases is a public health responsibility, it is typically mandated by law and health regulations, not specifically a requirement that nurses *always* report to the Board of Nursing in Texas. Reporting protocols usually involve health departments.
Choice B rationale
Parents declining treatment for a child can raise ethical and legal concerns, potentially involving child protective services or the legal system, but it is not always a direct reporting requirement to the Texas Board of Nursing unless it involves professional misconduct by a nurse.
Choice C rationale
A patient's decision to leave against medical advice is a matter of patient autonomy. While nurses document this and ensure the patient understands the risks, it is not typically a mandatory reporting situation to the Texas Board of Nursing unless there are specific concerns about the nurse's conduct related to the discharge.
Choice D rationale
Abuse of older adults by another nurse directly involves the professional conduct and potential harm caused by a licensed nurse. The Texas Board of Nursing is responsible for regulating nursing practice and ensuring patient safety, making it mandatory for nurses to report such instances of misconduct by a colleague.
Correct Answer is A
Explanation
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.
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