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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. While it’s important to assess whether the client has already taken pain medication, this should not be the first intervention. The priority is to assess the client's current status and gather information to guide the next steps in care.
B. Observing nonverbal signs of pain can be helpful, but the first priority is to assess the cause of the pain and collect pertinent data to determine if it’s related to kidney stones or another condition. Nonverbal signs are secondary to clinical assessment.
C. Using a pain scale would be appropriate after performing an initial assessment to determine the cause of the pain. While this helps gauge pain intensity, it is not the most urgent action in the case of suspected kidney stones.
D. The first priority in a client with flank pain and a history of kidney stones is to collect a urine sample and strain it for calculi.

A. Advise the client to see his healthcare provider for immediate evaluation. B. Ask the client if he often spends time outside in the sun without a shirt. C. Encourage the client to keep checking the mole with a magnifying mirror. D. Offer to teach a family member how to monitor the skin around the mole.

Correct Answer is A

Explanation

A. A mole that changes color and size is concerning for melanoma, a type of skin cancer. Immediate evaluation by a healthcare provider is essential for diagnosis and possible biopsy.
B. While sun exposure can increase the risk of skin cancer, the priority is to have the mole evaluated by a healthcare provider rather than focus on past behaviors.
C. Encouraging self-monitoring is not a priority when the mole shows signs of malignancy.
D. Teaching family members to monitor is secondary to seeking professional evaluation.

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The nurse learns in report that a client is stuporous. Which assessment should the nurse perform to confirm this report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client who has a history of kidney stones and returns to the clinic with flank pain. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

A client asks the nurse to look at a mole located on the back. The client tells the nurse that the mole has changed from brown to black and enlarged in size. Which is the priority nursing action?

Correct Answer is A

Explanation

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