A nurse is preparing to assess an older client who is new to a medical-surgical unit. Upon entry to the client’s room, the nurse observes that the client answers questions appropriately but falls back to sleep immediately after their responses. Which of the following best describes the client’s level of consciousness?
Obtunded
Stuporous
Lethargic
Alert
The Correct Answer is C
Choice A Reason:
Obtunded describes a state where the patient has a decreased level of consciousness and is difficult to arouse. They may respond slowly and be somewhat confused. This level of consciousness is more severe than lethargy and typically requires more vigorous stimulation to elicit a response. The client’s ability to answer questions appropriately before falling back to sleep suggests a less severe impairment than obtundation.
Choice B Reason:
Stuporous refers to a condition where the patient is almost entirely unresponsive and can only be aroused by vigorous and repeated stimuli. This state is more severe than lethargy and obtundation. The client’s ability to respond appropriately to questions indicates a higher level of consciousness than stupor. Therefore, stuporous is not the correct description of the client’s condition.
Choice C Reason:
Lethargic describes a state where the patient is very drowsy but can be aroused to respond to questions and then falls back to sleep. This matches the client’s presentation as they are able to answer questions appropriately but fall asleep immediately afterward. Lethargy is a common level of altered consciousness in various medical conditions and is less severe than obtundation or stupor.
Choice D Reason:
Alert describes a state where the patient is fully awake, aware, and responsive to stimuli. The client’s tendency to fall back to sleep immediately after responding to questions indicates that they are not fully alert. Therefore, this term does not accurately describe the client’s level of consciousness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Cognitive Behavioral Therapy
Cognitive Behavioral Therapy (CBT) is the most effective non-pharmacological treatment for anxiety disorders. CBT focuses on identifying and challenging negative thought patterns and behaviors that contribute to anxiety. It teaches clients practical skills to manage their anxiety, such as relaxation techniques, exposure therapy, and cognitive restructuring. Research has consistently shown that CBT can significantly reduce anxiety symptoms and improve overall functioning.
Choice B Reason:
Psychoanalytic therapy
Psychoanalytic therapy, based on the theories of Freud, aims to uncover unconscious conflicts and past experiences that influence current behavior. While it can be beneficial for some individuals, it is generally not considered the first-line treatment for anxiety disorders. Psychoanalytic therapy tends to be long-term and may not provide the immediate relief that clients with severe anxiety need.
Choice C Reason:
Electroconvulsive (ECT) therapy
Electroconvulsive therapy (ECT) involves the use of electrical currents to induce seizures in the brain and is primarily used to treat severe depression and certain other mental health conditions. It is not typically used as a treatment for anxiety disorders. ECT is considered a last-resort treatment when other therapies have failed, and it is not suitable for managing anxiety symptoms in most cases.
Choice D Reason:
Family systems therapy
Family systems therapy focuses on improving communication and relationships within the family unit. While it can be helpful for addressing family dynamics and support, it is not specifically designed to treat anxiety disorders. Family therapy may be used as an adjunct to other treatments, but it is not the primary approach for managing anxiety symptoms.
Correct Answer is A
Explanation
Choice A Reason:
Wheezes are continuous, high-pitched, musical sounds that occur when air flows through narrowed or obstructed airways1. They can be heard during both inspiration and expiration and are commonly associated with conditions such as asthma, chronic obstructive pulmonary disease (COPD), and bronchitis. Wheezes are a key indicator of airway obstruction and require prompt medical attention to address the underlying cause.
Choice B Reason:
Rhonchi are low-pitched, continuous sounds that resemble snoring or gurgling. They are typically caused by secretions or obstructions in the larger airways. Unlike wheezes, rhonchi are not high-pitched and do not have a musical quality. They are often heard in conditions like chronic bronchitis and can sometimes be cleared with coughing.
Choice C Reason:
Fine crackles are discontinuous, high-pitched popping sounds heard during inspiration. They are caused by the sudden opening of small airways and alveoli that are collapsed or filled with fluid. Fine crackles are often associated with conditions such as pneumonia, heart failure, and pulmonary fibrosis. They are not continuous sounds and do not have the musical quality of wheezes.
Choice D Reason:
Vesicular sounds are normal breath sounds heard over most of the lung fields. They are soft, low-pitched, and rustling in quality during inspiration and are fainter during expiration. Vesicular sounds indicate normal, unobstructed airflow through the small airways and alveoli. They are not continuous or high-pitched and do not have a musical quality.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.