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 A

Explanation

Choice A rationale
Instructing the client on daily muscle stretching can help alleviate and relax muscle spasms, which is beneficial for a client diagnosed with multiple sclerosis.

Choice B rationale
Ordering a low-residual diet is not typically a part of the care plan for a client diagnosed with multiple sclerosis.
Choice C rationale
Encouraging the client to void every hour may not be necessary for a client diagnosed with multiple sclerosis, unless there are specific urinary symptoms present.
Choice D rationale
Providing total assistance with all activities of daily living may not be necessary for a client diagnosed with multiple sclerosis, as the level of assistance required can vary greatly depending on the severity of the disease.

A. “I can take analgesics every four hours for pain.”. B. “I will chew on the affected side to prevent swallowing issues.”. C. “I can still brush my teeth with no issues.”. D. “I will apply this protective eye shield before going to bed.”. .

Correct Answer is B

Explanation

Choice A rationale
Analgesics can be used to manage pain associated with Bell’s palsy. Therefore, this statement does not indicate a need for further education.
Choice B rationale

This is the correct answer. Chewing on the affected side can actually exacerbate swallowing issues. Therefore, this statement indicates a need for further education.
Choice C rationale
Brushing teeth should not be affected by Bell’s palsy. Therefore, this statement does not indicate a need for further education.
Choice D rationale
Applying a protective eye shield before going to bed is a recommended practice for patients with Bell’s palsy. This helps to protect the eye from injury and keep it moist, as Bell’s palsy can cause difficulty in blinking or closing the eye.

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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

The nurse is creating a plan of care for a client who has a recent diagnosis of multiple sclerosis. Which of the following should the nurse include in the client’s care plan?

Correct Answer is A

Explanation

In the context of outpatient care for a client diagnosed with Bell’s palsy, which of the following statements, if made by the client, would indicate the need for further education?

Correct Answer is B

Explanation

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