A patient is stuporous but reacts by withdrawing from painful stimuli. Which term is most appropriate for this patient?

Semicomatose

Somnolent

Lethargic

Comatose

Answer and Explanation

The Correct Answer is C

A. Semicomatose:

This term suggests a state between consciousness and coma. A patient who is semicomatose may exhibit some level of responsiveness but is typically unresponsive or only responds to intense stimuli.

B. Somnolent:

Somnolence refers to a state of drowsiness or sleepiness. A somnolent patient may appear sleepy, have difficulty staying awake, and may be slow to respond to stimuli. However, the withdrawal from painful stimuli described in the scenario suggests a higher level of responsiveness than what would typically be expected in a somnolent state.

C. Lethargic:

Lethargy describes a state of reduced alertness or responsiveness. A lethargic patient may appear drowsy, sluggish, and have diminished responses to stimuli. The description of the patient as stuporous (having a decreased level of consciousness) but still reacting by withdrawing from painful stimuli aligns with the characteristics of lethargy.

D. Comatose:

Coma refers to a state of profound unconsciousness where the patient is unresponsive to all stimuli, including painful stimuli. A comatose patient does not demonstrate any purposeful movement or response to stimuli. Since the patient in the scenario exhibits some response to painful stimuli by withdrawing, they do not meet the criteria for being comatose.

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Correct Answer is A

Explanation

A. "It is too early to tell. When the spinal shock subsides, we will know more."

This response is appropriate. Spinal shock can initially obscure the extent of neurological injury, and it may take time for the full extent of the injury to become apparent. By acknowledging this and suggesting that more information will be available once spinal shock subsides, the nurse provides a realistic perspective without prematurely predicting the outcome.

B. "You should talk to your physician about things of that nature."

This response may come across as dismissive or evasive. While it is true that the physician ultimately determines the patient's prognosis, the family may be seeking reassurance and guidance from the nurse as well.

C. "No. Significant recovery of function should occur in a few days."

This response is overly optimistic and potentially misleading. While some improvement may occur in the days following a spinal cord injury, significant recovery of function within a few days is unlikely, especially in cases of flaccid paralysis of all extremities.

D. "Yes. In all likelihood, the paralysis is probably permanent."

This response is overly pessimistic and lacks sensitivity. It may unnecessarily distress the family and extinguish hope for the patient's recovery.

A. Monitor for elevated blood pressure. B. Provide analgesia for headaches. C. Prevent bladder distention. D. Elevate the client's head.

Correct Answer is C

Explanation

A.While monitoring for elevated blood pressure is important in identifying autonomic dysreflexia once it occurs, it does not prevent the condition. The nurse should focus on eliminating potential triggers, such as bladder distention or constipation, to prevent the occurrence.

B.Headaches are a symptom of autonomic dysreflexia, often related to severe hypertension. While treating the headache may alleviate discomfort, it does not address the underlying cause, nor does it prevent the onset of autonomic dysreflexia.

C.Bladder distention is a common trigger for autonomic dysreflexia in individuals with spinal cord injuries. The nurse should ensure that the client's bladder is regularly emptied to prevent overdistention, which can stimulate the autonomic reflex and trigger AD.

D.Elevating the head is an intervention used during an episode of autonomic dysreflexia to help lower blood pressure and reduce symptoms. However, this action does not prevent the condition from occurring.

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A patient is stuporous but reacts by withdrawing from painful stimuli. Which term is most appropriate for this patient?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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