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A nurse is assessing the level of consciousness of a patient who sustained a head injury in a motor vehicle accident. The nurse notes that the patient appears drowsy most of the time but makes spontaneous movements. The nurse is able to wake the patient by gently shaking him and calling his name.

What level of consciousness would the nurse document?

A.

Comatose

B.

Awake and alert

C.

Lethargic

D.

Stuporous

Answer and Explanation

The Correct Answer is C

A. Comatose:

Coma refers to a state of deep unconsciousness where the individual is unresponsive to stimuli, including pain or external stimulation. In the scenario described, the patient is not comatose because they can be awakened by gentle shaking and calling their name.

B. Awake and alert:

This term describes a state of full alertness and responsiveness to the environment. The patient in the scenario is not fully awake and alert since they appear drowsy most of the time and require external stimuli to be awakened.

C. Lethargic:

Lethargy is characterized by drowsiness, reduced alertness, and a sluggish response to stimuli. In the scenario, the patient is described as drowsy most of the time but can be awakened by gentle shaking and calling their name. This aligns with the characteristics of lethargy.

D. Stuporous:

Stupor is a state of reduced responsiveness where the individual can be aroused only by vigorous or painful stimuli. The patient in the scenario does not fit the criteria for stupor as they can be awakened by gentle shaking and calling their name.


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Related Questions

Correct Answer is B

Explanation

A. Redo the initial assessment and document current findings:

This option suggests repeating the entire initial assessment. While reassessment is important, redoing the entire initial assessment may not be necessary. Instead, a focused assessment on the specific area of concern (skin integrity) is more appropriate.

B. Perform and document a focused assessment of skin integrity:

This is the recommended choice. If unexpected findings are observed during care, such as reddened areas over bony prominences, it is important to conduct a focused assessment on the skin to identify any issues and document the findings accurately.

C. Correct the initial assessment form:

Simply correcting the initial assessment form may not address the immediate need for assessing and addressing the reddened areas. It is more crucial to perform a focused assessment on the skin.

D. Conduct and document an emergency assessment:

Reddened areas over bony prominences may not necessarily indicate an emergency. However, addressing the issue promptly is important. A focused assessment would be more appropriate than conducting a full emergency assessment.

Correct Answer is C

Explanation

A. Comatose:

Coma refers to a state of deep unconsciousness where the individual is unresponsive to stimuli, including pain or external stimulation. In the scenario described, the patient is not comatose because they can be awakened by gentle shaking and calling their name.

B. Awake and alert:

This term describes a state of full alertness and responsiveness to the environment. The patient in the scenario is not fully awake and alert since they appear drowsy most of the time and require external stimuli to be awakened.

C. Lethargic:

Lethargy is characterized by drowsiness, reduced alertness, and a sluggish response to stimuli. In the scenario, the patient is described as drowsy most of the time but can be awakened by gentle shaking and calling their name. This aligns with the characteristics of lethargy.

D. Stuporous:

Stupor is a state of reduced responsiveness where the individual can be aroused only by vigorous or painful stimuli. The patient in the scenario does not fit the criteria for stupor as they can be awakened by gentle shaking and calling their name.

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