The nurse learns in report that a client is stuporous. Which assessment should the nurse perform to confirm this report?
Observe for any facial asymmetry.
Determine the response to stimuli.
Assess for a positive Romberg sign.
Check the pupillary response to light.
The Correct Answer is B
A. Facial asymmetry may indicate neurological issues, but it does not directly assess the stuporous state.
B. A stuporous state is characterized by a reduced level of consciousness, and the nurse should assess
the client’s response to stimuli to confirm the report of stupor.
C. A positive Romberg sign indicates a balance issue, but it is not directly related to confirming a stuporous state.
D. While pupillary response is important, it does not provide sufficient information to confirm a stuporous state without assessing responsiveness to stimuli.
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Related Questions
Correct Answer is D
Explanation
A. While comparing the range of motion of both legs could be useful for detecting joint or muscle- related issues, it does not directly address the vascular concerns suggested by the shiny skin and absence of hair growth. These signs are more likely related to poor circulation, which requires different diagnostic approaches.
B. Asking about feelings of weakness or hunger may be more relevant to assessing the client’s blood glucose control, but it is not directly related to the symptoms of shiny skin and hair loss on the lower legs, which suggest peripheral vascular changes common in diabetes.
C. While measuring blood glucose levels is important in managing diabetes, it will not help to assess the vascular insufficiency suggested by the physical findings. However, managing blood glucose is crucial to preventing further complications.
D. Palpating the dorsalis pedis pulses is the most appropriate next step. Decreased or absent pulses in the feet and lower extremities are commonly associated with peripheral vascular disease, which is common in clients with diabetes due to poor circulation.
Correct Answer is D
Explanation
A. This is not specific for egophony. While lung auscultation is part of a thorough assessment, egophony is assessed when the patient vocalizes a specific sound, not just breathing in and out.
B. This is a technique used to assess for whispered pectoriloquy, not egophony. The nurse would be looking for clarity of the whispered words, which is different from assessing for egophony.
C. This test is used to assess for bronchophony, where the nurse listens for clarity or increased volume of spoken words over the lungs. It is not related to egophony, which is a change in the sound when the client says "E."
D. This is the correct method for assessing egophony. In this test, the client is asked to say "E," and the nurse listens for any change in the sound. Normally, the "E" should sound like "E." If it sounds like "A," it indicates egophony, which can suggest a lung consolidation, such as might occur with a lung abscess.
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