The nurse is caring for a patient and is monitoring the level of consciousness hourly per hospital mandated policy. The nurse initially assesses the patient be awake with forgetfulness and difficulty following commands without prompting or reminders. 1 hour later, the nurse assesses the patient to be sleepy with slow and delayed responses to stimuli. Describe the two assessments of level of consciousness:

Confusion, Lethargic

Confusion, Stupor

Lethargic, Obtunded

Conscious, Confusion

Answer and Explanation

The Correct Answer is A

A. The initial assessment describes a state of confusion where the patient is awake but experiencing forgetfulness and difficulty following commands. The subsequent assessment indicates lethargy, as the patient is now sleepy and has slow responses, which aligns with the definitions of confusion and lethargy.
B. While confusion is present in the first assessment, stupor describes a state of near-unconsciousness, which does not match the second assessment.
C. Although lethargy is appropriate for the second assessment, obtunded refers to a state where the patient is less aware and has difficulty arousing, which is not accurately described here.
D. The first assessment indicates confusion, but the patient is not fully conscious as described in the second assessment, which does not align with this option.

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Correct Answer is ["62.5"]

Explanation

To determine the IV pump rate, we need to calculate the flow rate in milliliters per hour (mL/h).

Given:

Total volume: 500 mL
Infusion time: 8 hours

Calculation:

Flow rate = Total volume / Infusion time
Flow rate = 500 mL / 8 hours
Flow rate = 62.5 mL/h

A. contribute to the medical diagnosis of the client. B. provide a baseline assessment against which to evaluate changes in function. C. plan care to protect the client from falls/injury. D. anticipate other neurologic deficits that may arise.

Correct Answer is C

Explanation

A. Contributing to the medical diagnosis is a secondary goal for nursing care. The nurse's primary role is to ensure patient safety and prevent complications such as falls, which are more likely in patients with sensory and motor impairments.
B. While establishing a baseline for future comparison is important, it is not the most immediate concern. The nurse's priority is preventing falls and injury related to the impairment.
C. The priority in this case is to protect the client from falls or injury, as impaired motor and sensory function in the lower extremities increases the risk for accidents. Preventing injury will guide the development of the care plan, such as implementing fall precautions.
D. Anticipating other neurologic deficits is valuable but not the most urgent concern compared to protecting the client from the immediate risk of falls.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is to receive 500 mL of IV fluid over 8 hours. At what rate should the nurse set the IV pump?

Correct Answer is ["62.5"]

Explanation

The nurse determines through neurologic testing that a patient has sensory and motor impairment of bilateral lower extremities. The most important reason to assess for this in the client is to:

Correct Answer is C

Explanation

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