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 C

Explanation

A. While this approach may seem less intrusive, it can create confusion and may prevent the client from feeling fully understood. Asking vague questions could make it more difficult to get useful information about the client's health concerns.
B. Sharing personal values is generally not appropriate in a clinical interview, as it could create boundaries that compromise the professional relationship. The nurse should maintain objectivity and empathy without sharing personal beliefs.
C. Starting with less sensitive questions allows the nurse to build rapport and trust with the client before delving into more personal or difficult topics. This approach is helpful in easing the client into more sensitive discussions.
D. Asking the most difficult questions right away can overwhelm the client, especially if they are hesitant or uncomfortable. It is better to establish a trusting relationship first and allow the client to open up at their own pace.

A. Palpate the radial pulses in both arms for a deficit. B. Use the stethoscope to listen over the carotid artery. C. Feel the volume of the dorsalis pedis and posterior tibialis pulses. D. Auscultate the apical pulse at the point of maximal impulse.

Correct Answer is D

Explanation

A. Palpating the radial pulses might not detect irregularities in pulse rate or rhythm as effectively as auscultation at the apical site.
B. Listening over the carotid artery may be useful in certain situations but is not the preferred method for assessing overall pulse rate.
C. Feeling the dorsalis pedis and posterior tibialis pulses provides information about peripheral circulation but does not assess the overall heart rate.
D. Auscultating the apical pulse is the most accurate method to assess the pulse rate, especially in clients with cardiovascular disease, as it provides direct measurement of heart activity.

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

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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