The nurse is caring for a patient whose recent health history includes an altered level of consciousness. What should be the nurse’s initial action when assessing this patient?

Assessing the patient’s ability to follow complex commands

Assessing the patient’s judgment

Assessing the patient’s verbal response

Assessing the patient’s response to pain

Answer and Explanation

The Correct Answer is D

Choice D rationale
When assessing a patient with an altered level of consciousness, the nurse’s initial action should be to assess the patient’s response to pain. This is a fundamental part of the neurological examination and can provide valuable information about the patient’s level of consciousness and neurological function. Pain response can be assessed by applying a painful stimulus, such as a pinch, and observing the patient’s reaction.
Choice A rationale
Assessing the patient’s ability to follow complex commands is an important part of the neurological examination, but it is not typically the initial action when assessing a patient with an altered level of consciousness. This assessment requires a higher level of cognitive function and may not be possible in a patient with significantly altered consciousness.
Choice B rationale
Assessing the patient’s judgment is an important part of the mental status examination, but it is not typically the initial action when assessing a patient with an altered level of consciousness. Like the ability to follow complex commands, judgment requires a higher level of cognitive function and may not be assessable in a patient with significantly altered consciousness.

Choice C rationale
Assessing the patient’s verbal response is an important part of the neurological examination, but it is not typically the initial action when assessing a patient with an altered level of consciousness. The patient’s ability to speak and the content of their speech can provide important information about their neurological function, but this assessment may not be possible in a patient with significantly altered consciousness.

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Free Nursing Study Resources

Correct Answer is ["4 "]

Explanation

The nurse is preparing to administer 40 mg of furosemide intravenously. The available furosemide is 10 mg/1 mL.

Step 1 is: Calculate the dose in mL using the formula: (Desired dose ÷ Available dose) × Volume.

Step 2 is: Substitute the given values into the formula: (40 mg ÷ 10 mg) × 1 mL = 4 mL. The nurse should administer 4 mL per dose.

A. Follow up by having the client perform the Rinne test B. Reposition the client supine to ensure safety. C. Document successful completion of the assessment. D. Facilitate a referral to a neurologist.

Correct Answer is C

Explanation

Choice A rationale
The Rinne test is a hearing test used to evaluate the difference between sound transmission through air conduction versus bone conduction. It is not typically used following a Romberg test, which evaluates balance.
Choice B rationale
While ensuring the patient’s safety is always important, repositioning the client supine is not the typical response to slight swaying during a Romberg test.
Choice C rationale
Slight swaying during a Romberg test is considered normal. Therefore, documenting successful completion of the assessment would be the appropriate action.
Choice D rationale
A referral to a neurologist is not typically necessary for slight swaying during a Romberg test, as this is considered within normal limits.

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The nurse is caring for a patient whose recent health history includes an altered level of consciousness. What should be the nurse’s initial action when assessing this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer 40 mg of furosemide intravenously. The available furosemide is 10 mg/1 mL. How many mL should the nurse administer per dose? Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.

Correct Answer is ["4 "]

Explanation

During the performance of a Romberg test, the nurse observes the client sway slightly. What action should the nurse take?

Correct Answer is C

Explanation

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