After completing a neurological assessment, the nurse documents that the client is stuporous. Which of the following describes this level of consciousness?
Minimal movement, verbal responses limited to sounds, awakens briefly only with extreme vigorous stimulation.
Extremely drowsy, minimally responsive, limited ability to follow commands, vigorous stimulation needed to waken.
Alert and oriented x3, sluggish, drowsy, wakes to voice or gentle shaking.
Does not respond to verbal stimuli, does not speak, decorticate/decerebrate posturing in response to pain.
The Correct Answer is A
Choice A reason: This is the correct answer because this describes a stupor, which is a state of near-unconsciousness or reduced responsiveness. A stuporous client shows minimal movement and verbal responses and requires extreme vigorous stimulation such as painful stimuli to awaken briefly.
Choice B reason: This is incorrect because this describes obtundation, which is a state of reduced alertness or awareness. An obtunded client is extremely drowsy and minimally responsive and requires vigorous stimulation such as shaking or shouting to wake.
Choice C reason: This is incorrect because this describes lethargy, which is a state of decreased energy or activity. A lethargic client is alert and oriented x3 (to person, place, and time), but sluggish and drowsy, and wakes to voice or gentle shaking.
Choice D reason: This is incorrect because this describes a coma, which is a state of deep unconsciousness or unresponsiveness. A comatose client does not respond to verbal stimuli or speak and shows abnormal posturing in response to pain, such as decorticate (flexion of arms and extension of legs) or decerebrate (extension of arms and legs).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: This is the correct choice. Washing towels, sheets, and pillowcases is a home care instruction that the nurse will offer to the client, as it prevents reinfection and transmission of bacteria or viruses. The client has conjunctivitis, which is inflammation of the conjunctiva or thin membrane that covers the white part of the eye and lines the eyelids. It can be caused by bacteria, viruses, allergies, or irritants.
Choice B Reason: This is an incorrect choice. Using antifungal drops 3 times a day is not a home care instruction that the nurse will offer to the client, as it is not effective for conjunctivitis. Antifungal drops are used for fungal infections of the eye, which are rare and usually occur after trauma or surgery. The client may need antibiotic or antiviral drops, depending on the cause of conjunctivitis.
Choice C Reason: This is an incorrect choice. Scheduling a sexually transmitted infection (STI/STD) exam is not a home care instruction that the nurse will offer to the client, as it is not relevant for conjunctivitis. STIs can affect the eyes, but they usually cause different symptoms, such as redness, pain, or discharge from the urethra or vagina. The client may need to be tested for STIs if they have other risk factors or signs of infection.
Choice D Reason: This is an incorrect choice. Avoiding going outside during daylight hours is not a home care instruction that the nurse will offer to the client, as it is not necessary for conjunctivitis. The client may experience sensitivity to light, but they can wear sunglasses or avoid direct sunlight to protect their eyes. The client should also avoid rubbing or touching their eyes, wear glasses instead of contact lenses, and discard any eye makeup or cosmetics that may be contaminated.
Correct Answer is B
Explanation
Choice A Reason: Hemorrhage is not a complication of an acute spinal cord injury, but rather a possible cause of it. Hemorrhage can occur due to trauma or rupture of blood vessels in or around the spinal cord, leading to compression and damage of the nerve tissue.
Choice B Reason: This is the correct choice. Spinal shock is a complication of an acute spinal cord injury that occurs within minutes to hours after the injury. It is characterized by loss of sensation, motor function, reflexes, and autonomic function below the level of injury. It is caused by transient disruption of nerve conduction and synaptic transmission in the spinal cord.
Choice C Reason: Apoptosis is not a complication of an acute spinal cord injury, but rather a cellular process that occurs after it. Apoptosis is programmed cell death that occurs in response to injury or stress. It can lead to further loss of neurons and glial cells in the spinal cord over time.
Choice D Reason: Neurogenic shock is a complication of an acute spinal cord injury that occurs within hours to days after the injury. It is characterized by hypotension, bradycardia, and peripheral vasodilation due to loss of sympathetic tone and unopposed parasympathetic activity. It is caused by disruption of autonomic pathways in the spinal cord.
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