When assessing a patient with altered level of consciousness, which of the following would the nurse assess first?
Respiratory status
Alertness
Motor response
Verbal response
The Correct Answer is A
Choice A: Respiratory status is the first priority, as it can affect the oxygenation and perfusion of the brain and other vital organs. The nurse should assess the rate, rhythm, depth, and quality of breathing, as well as the use of accessory muscles, chest expansion, and lung sounds.
Choice B: Alertness is not the first priority, but rather a component of the level of consciousness. The nurse should assess the patient's ability to open their eyes spontaneously or in response to stimuli, as well as their orientation to person, place, time, and situation.
Choice C: Motor response is not the first priority, but rather a component of the level of consciousness. The nurse should assess the patient's ability to move their limbs voluntarily or in response to stimuli, as well as their muscle strength, tone, and coordination.
Choice D: Verbal response is not the first priority, but rather a component of the level of consciousness. The nurse should assess the patient's ability to speak clearly and coherently, as well as their content and appropriateness of speech.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: Thickened liquids or pureed diet is correct because it can prevent aspiration, choking, or malnutrition in stroke patients. A stroke can impair the patient's ability to swallow, chew, or control their tongue and mouth movements. This can cause food or liquids to enter the airway instead of the esophagus, leading to pneumonia or death. A thickened liquid or pureed diet consists of foods that are smooth, soft, and easy to swallow. The nurse should assess the patient's swallowing function and provide appropriate food and drink consistency.
Choice B: Regular diet is incorrect because it can be unsafe or unsuitable for stroke patients. A regular diet consists of foods that are solid, crunchy, or sticky and require normal chewing and swallowing abilities. The nurse should not give a regular diet to a stroke patient unless they have passed a swallowing evaluation and have no signs of dysphagia.
Choice C: Renal diet is incorrect because it is not specific to stroke patients. A renal diet is designed for patients with kidney disease or failure. It limits the intake of sodium, potassium, phosphorus, and protein to reduce the workload and waste products of the kidneys. The nurse should not give a renal diet to a stroke patient unless they also have a kidney condition and a doctor's order.
Choice D: Cardiac diet is incorrect because it is not specific to stroke patients. A cardiac diet is designed for patients with heart disease or risk factors. It limits the intake of saturated fat, cholesterol, sodium, and sugar to lower the blood pressure and cholesterol levels and prevent further damage to the heart. The nurse should not give a cardiac diet to a stroke patient unless they also have a heart condition and a doctor's order.
Correct Answer is D
Explanation
Choice A: Incontinence is a cause of skin breakdown, as it can expose the skin to moisture, bacteria, and chemicals that can irritate and damage the skin.
Choice B: Altered level of consciousness is a cause of skin breakdown, as it can impair the patient's ability to sense and report pain, discomfort, or pressure on the skin.
Choice C: Immobility is a cause of skin breakdown, as it can reduce the blood flow and oxygen to the skin and increase the pressure on bony prominences.
Choice D: All of the above is correct, as all of these factors can contribute to skin breakdown.
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