The nurse is caring for a client whose recent health history includes an altered LOC. What should be the nurse's first action when assessing this client?

Assessing the client's verbal response.

Assessing the client's response to pain.

Assessing the client's judgment.

Assessing the client's ability to follow complex commands.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Assessing the client's verbal response is the first step in evaluating their level of consciousness (LOC). It provides immediate information about their ability to communicate and follow commands.

Choice B rationale

Assessing the client's response to pain is a later step in the LOC assessment if the client does not respond to verbal stimuli. It helps determine the level of consciousness if the client is not verbally responsive.

Choice C rationale

Assessing the client's judgment is part of a cognitive assessment but is not the first action when assessing LOC. It evaluates higher brain functions, not the initial level of responsiveness.

Choice D rationale

Assessing the client's ability to follow complex commands is part of a cognitive assessment and provides information about higher brain function but is not the first step in LOC assessment.

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Correct Answer is D

Explanation

Choice A rationale

Ataxic gait is characterized by uncoordinated movement, wide-based steps, and irregular distances between steps, often seen in cerebellar dysfunctions.

Choice B rationale

Dystrophic gait is associated with muscle weakness, often seen in muscular dystrophies, where there is difficulty in walking, a waddle-like walk, and frequent falls.

Choice C rationale

Steppage gait is associated with foot drop, where the individual lifts their knees higher than usual to avoid dragging their toes, often seen in peripheral neuropathies.

Choice D rationale

Helicopod gait involves the feet making a half-circle with each step and is often seen in individuals with certain neurologic disorders, such as hemiplegia or certain types of ataxia.

A. Dryness of the eyes. B. Skin peeling on eyelids. C. Pruritus of the eyes. D. Burning of the eyes.

Correct Answer is ["A","B","D"]

Explanation

Choice A rationale

Dryness of the eyes, or xerophthalmia, is a common symptom of keratoconjunctivitis. It indicates the involvement of the conjunctiva and cornea, often seen in conditions like Stevens-Johnson syndrome or toxic epidermal necrolysis.

Choice B rationale

Skin peeling on the eyelids suggests severe involvement of the ocular adnexa and can be a sign of advancing keratoconjunctivitis. This symptom reflects significant mucocutaneous damage.

Choice C rationale

Pruritus, or itching, is less specific for keratoconjunctivitis and more commonly associated with allergic reactions or less severe irritations. It is not a primary indicator of the disease's progression.

Choice D rationale

Burning of the eyes is a symptom of keratoconjunctivitis, indicating inflammation and irritation of the conjunctiva and cornea. This symptom helps in identifying the progression of the condition. .

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The nurse is caring for a client whose recent health history includes an altered LOC. What should be the nurse's first action when assessing this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term?

Correct Answer is D

Explanation

The nurse is assessing a client with toxic epidermal necrolysis (TEN). What assessment data would indicate that the client may be progressing to keratoconjunctivitis? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

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