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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Assessing pupils is important, but it provides only partial information about the overall neurologic status and does not give a comprehensive picture of improvement or deterioration.
B. Vital signs can indicate some changes in condition but are not specific to neurologic status and do not provide detailed insight into cognitive or motor function.
C. Performing serial Glasgow Coma Scales allows for a standardized and objective assessment of a patient's level of consciousness, motor responses, and verbal responses over time, making it the most effective method to evaluate neurologic status.
D. The Mini Mental Status Exam provides useful information about cognitive function but may not capture acute changes in neurologic status as effectively as the Glasgow Coma Scale.
Correct Answer is A
Explanation
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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