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 A

Explanation

A. Asking the client directly about the medications they have taken for their cough provides specific
information about the treatments they’ve used, including over-the-counter or prescription options.
B. Asking if they have been prescribed medications for the cough might miss important details about over-the-counter medications or self-treatment.
C. Asking about generic brands of cough syrup is too specific and may miss other relevant medications the client is using to manage their chronic cough.
D. Asking about current medications is important for general health information, but it does not directly address treatment specific to the cough.

A. Listen to the heart sounds using the bell of a stethoscope. B. Use a Doppler ultrasound to hear the heartbeat. C. Obtain a pulse oximeter reading from two extremities. D. Auscultate for one minute with the stethoscope's diaphragm.

Correct Answer is A

Explanation

A. The bell of the stethoscope is best for detecting low-pitched sounds like murmurs or extra heart sounds.
B. A Doppler ultrasound is not necessary for routine auscultation of heart sounds.
C. Pulse oximetry does not provide relevant information about heart sounds.
D. Auscultating with the diaphragm is better for high-pitched sounds, so the bell is preferred for extra heart sounds.

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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

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