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

Administering a bolus of normal saline addresses fluid volume but does not directly address the respiratory effort increase or potential increased ICP, which is the most concerning aspect of the head injury.

Choice B rationale

Administering bronchodilators and monitoring LOC may help with respiratory issues but does not address the underlying problem of increased ICP, which could be causing the increased respiratory effort.

Choice C rationale

Increasing the client's bed height and reassessing in 30 minutes might temporarily help, but it is not the most immediate and appropriate intervention. The client’s symptoms suggest a more urgent issue.

Choice D rationale

Informing the care team and assessing for further signs of increased ICP is crucial. Increased respiratory effort in a client with head injury can indicate rising intracranial pressure, which requires immediate medical attention to prevent further complications.

A. Cushing syndrome. B. Adrenal crisis. C. Arginine vasopressin deficiency (AVP-D). D. Syndrome of inappropriate antidiuretic hormone (SIADH).

Correct Answer is C

Explanation

Choice A rationale

Cushing syndrome is not associated with high urine output post-craniotomy. It is related to excessive cortisol production leading to weight gain, hypertension, and other symptoms.

Choice B rationale

Adrenal crisis involves insufficient production of cortisol and aldosterone, leading to symptoms like hypotension, fatigue, and abdominal pain, not high urine output.

Choice C rationale

Arginine vasopressin deficiency (AVP-D), also known as diabetes insipidus, causes the kidneys to excrete large amounts of dilute urine due to lack of ADH, leading to high urine output.

Choice D rationale

Syndrome of inappropriate antidiuretic hormone (SIADH) causes water retention and low urine output due to excess ADH, not the increased urine output seen in the scenario.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who sustained a moderate head injury following a bicycle accident. The nurse's most recent assessment reveals that the client's respiratory effort has increased. What is the nurse's most appropriate action?

Correct Answer is D

Explanation

What should the nurse suspect when hourly assessment of urine output on a client post craniotomy exhibits a urine output from a catheter of 1,500 mL for two consecutive hours?

Correct Answer is C

Explanation

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