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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Correct Answer is C

Explanation

Choice A rationale

Assessing lung sounds is an important part of monitoring a patient’s respiratory status, but it may not be the most immediate action if the patient is finding it increasingly difficult to breathe.

Choice B rationale

While explaining the progression of the syndrome is important for patient education, it may not be the most immediate action if the patient is experiencing difficulty breathing.

Choice C rationale

Guillain-Barre syndrome can affect the muscles used for breathing, resulting in a weakened or paralyzed diaphragm, which can lead to an ineffective breathing pattern. Therefore, if a patient states that it is getting harder to take a deep breath, the nurse should call the physician and prepare for possible intubation.

Choice D rationale

Encouraging the client to cough may not be the most appropriate action if the patient is finding it increasingly difficult to breathe.

A. Carbonic anhydrase inhibitors B. Prostaglandins C. Alpha-agonists D. Beta-blockers

Correct Answer is B

Explanation

The correct answer is: = b. Prostaglandins

Choice A: Carbonic anhydrase inhibitors: These medications can be used for glaucoma, but they are not typically the first-line treatment due to potential side effects.

Choice B: Prostaglandins (Correct Answer) These are often the preferred initial medication for glaucoma because they are effective at lowering eye pressure, have minimal systemic side effects, and are typically used once daily.

Choice C: Alpha-agonists: These medications can be used as an adjunct to other glaucoma medications but are not usually the first choice due to potential side effects like dry mouth and fatigue.

Choice D: Beta-blockers: While once a common first-line treatment, beta-blockers have been largely replaced by prostaglandins due to potential side effects like slowed heart rate and worsened breathing problems.

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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 caring for a client recently diagnosed with Guillain-Barre syndrome. The client states, “It is getting harder to take a deep breath.”. Which action by the nurse is most appropriate?

Correct Answer is C

Explanation

The patient with glaucoma is usually started on the lowest dose of medication. Which of the following is the preferred initial ophthalmic medication?

Correct Answer is B

Explanation

A client with trigeminal neuralgia has been given suggestions to minimize episodes of pain. Which statement, if made by the client, would indicate the need for further teaching?

The nurse is caring for a client that has been diagnosed with aphasia. How can the nurse communicate effectively with the client?

The nurse is educating a patient who has been newly prescribed eye medications to treat glaucoma. How can the nurse best determine if the patient can safely and effectively self-administer the medications?

The nurse is precepting a new nurse who is caring for a patient with a history of Huntington’s disease. The new nurse is preparing to feed the patient lunch. What action by the new nurse would cause the precepting nurse to intervene?

The nurse is assessing a patient with a suspected stroke. What assessment finding is most suggestive of a stroke?

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

While waiting for an appointment in the doctor’s office, a patient experiences a convulsive seizure. The nurse is immediately notified. What nursing care should be provided at this time? (Select all that apply.)

A patient with hypotension has an order for 1000 mL of 0.9% Normal Saline over 3 hours. The tubing drop factor is 10 gtt/mL. How many gtt/min should be given? (This is a med math nd does not require options)