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NurseDive Free Nursing Practice Question
A client is extremely drowsy, minimally responsive, and has a difficult time following commands. With vigorous stimulation the client awakens but quickly falls back asleep. What level of consciousness does this describe?
A. lethargy
Lethargy is a state of reduced alertness and awareness, where the client is sleepy but can be aroused easily and respond appropriately.
B. obtunded
Obtunded is a state of decreased alertness and responsiveness, where the client is difficult to arouse and has limited interaction with the environment.
C. stuporous
Stuporous is a state of deep unconsciousness, where the client is unresponsive to most stimuli and requires painful stimulation to elicit a response.
D. confusion
Confusion is a state of impaired orientation and memory, where the client is awake but has difficulty understanding and following commands.
This question is an excerpt from Nurse Dive's nursing test bank - Ati med surg adult care 2 proctored exam. Take the full exam now
Similar Questions
A nurse working on a medical unit is caring for a client who is prescribed seizure precautions. Which of the following interventions should the nurse Include in the client's plan of care?
A. Obtain IV access.
Correct. Obtaining IV access is an important intervention for a client who is prescribed seizure precautions, as it allows for the administration of anticonvulsant medications and fluids in case of a seizure.
B. Place the client's bed in the high position.
Incorrect. Placing the client's bed in the high position increases the risk of injury if the client falls out of bed during a seizure. The bed should be in the lowest position with the side rails up and padded.
C. Keep a padded tongue blade available at the client's bedside.
Incorrect. Keeping a padded tongue blade available at the client's bedside is not recommended, as it can cause oral trauma or airway obstruction if inserted during a seizure. The nurse should never force anything into the client's mouth during a seizure.
D. Keep the lights on when the client is sleeping.
Incorrect. Keeping the lights on when the client is sleeping is not necessary for a client who is prescribed seizure precautions, as it can interfere with the client's rest and sleep quality. The nurse should provide a quiet and dark environment for the client to sleep.
A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority?
A. Monitor the client's electrolyte levels.
Incorrect. Monitoring the client's electrolyte levels is important, but not the highest priority for an unconscious client who may have impaired airway clearance.
B. Suction saliva from the client's mouth.
Correct. Suctioning saliva from the client's mouth is the highest priority intervention, as it can prevent aspiration and maintain a patent airway.
C. Perform passive range of motion on each extremity.
Incorrect. Performing passive range of motion on each extremity is beneficial for preventing contractures and promoting circulation, but not the highest priority for an unconscious client who may have impaired airway clearance.
D. Record the client's intake and output.
Incorrect. Recording the client's intake and output is necessary for evaluating fluid balance and renal function, but not the highest priority for an unconscious client who may have impaired airway clearance.
A nurse is preparing to administer Tissue plasminogen activator (tPA). What is the likely reason the client will receive this treatment?
A. The client is having an active seizure
Incorrect. The client is having an active seizure is not a reason to administer tPA, which is a clotbusting drug that dissolves blood clots and restores blood flow to the brain. Seizures are not caused by blood clots, but by abnormal electrical activity in the brain.
B. The client experienced a hemorrhagic stroke
Incorrect. The client experienced a hemorrhagic stroke is not a reason to administer tPA, which is a contraindication for this treatment. Hemorrhagic strokes are caused by bleeding in the brain, and tPA can worsen the bleeding and increase the risk of complications.
C. The client suffers from Parkinson's disease
Incorrect. The client suffers from Parkinson's disease is not a reason to administer tPA, which has no effect on this condition. Parkinson's disease is a degenerative disorder that affects the movement and coordination of the body, caused by the loss of dopamineproducing neurons in the brain.
D. The client experienced an ischemic stroke
Correct. The client experienced an ischemic stroke is a reason to administer tPA, which is the standard treatment for this condition if given within 4.5 hours of symptom onset. Ischemic strokes are caused by blood clots that block the blood vessels in the brain, and tPA can dissolve the clots and restore blood flow to the affected area.