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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
Choice A rationale
Pinpoint pupils can indicate opioid use or damage to the pons, a part of the brainstem. This finding warrants further evaluation to determine the underlying cause and appropriate intervention.
Choice B rationale
Absence of pupillary response suggests severe brain injury or brainstem dysfunction. It is a critical finding that requires immediate medical attention to address potential life-threatening conditions.
Choice C rationale
Pupil reaction to light is a normal response indicating intact cranial nerve function. This finding does not raise neurologic concerns and does not require further investigation.
Choice D rationale
Quick pupil reaction is a normal response and indicates healthy cranial nerve function. This finding is not associated with neurologic concerns.
Choice E rationale
Unequal pupils, or anisocoria, can indicate increased intracranial pressure, brain injury, or nerve damage. This finding requires prompt assessment and intervention to prevent further complications.
Correct Answer is B
Explanation
Choice A rationale
Lamellae are layers of bone tissue arranged in concentric circles in compact bone, not cells responsible for bone matrix secretion.
Choice B rationale
Osteoblasts are the cells responsible for the secretion of bone matrix. They produce collagen and other substances necessary for bone formation and growth.
Choice C rationale
Osteocytes are mature bone cells derived from osteoblasts. They maintain bone tissue but do not secrete bone matrix.
Choice D rationale
Osteoclasts are cells involved in the resorption of bone tissue, not the secretion of bone matrix. They break down bone tissue during growth and repair.
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