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.

Answer and Explanation

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).

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Correct Answer is D

Explanation

Choice A Reason: This is incorrect because nystagmus is not a response to stimuli, but a condition that causes involuntary eye movements. Nystagmus can be caused by various factors, such as inner ear disorders, brain lesions, or drug toxicity, but not necessarily by cervical spine injury.

Choice B Reason: This is incorrect because decorticate positioning is a response to stimuli that indicates damage to the cerebral cortex or the corticospinal tract. Decorticate positioning is characterized by flexion of the arms and extension of the legs. It does not indicate cervical spine injury, which affects the spinal cord below the brainstem.

Choice C Reason: This is incorrect because lack of any response to stimuli can indicate various levels of brain damage or coma, but not specifically cervical spine injury. Lack of any response can also be influenced by other factors, such as sedation, hypothermia, or shock.

Choice D Reason: This is correct because decerebrate positioning is a response to stimuli that indicates damage to the brainstem or the upper cervical spine. Decerebrate positioning is characterized by extension and outward rotation of the arms and legs. It indicates a severe and life-threatening injury that can impair vital functions, such as breathing and blood pressure.

A. Slow cautious behaviors. B. Loss of depth perception. C. Overestimation of abilities. D. Hemianopsia.

Correct Answer is D

Explanation

Choice A reason: This is incorrect because slow cautious behaviors are more consistent with a stroke involving the right hemisphere. The right hemisphere controls spatial awareness, creativity, and intuition. A stroke affecting this hemisphere can cause impulsivity, poor judgment, and denial of deficits.

Choice B reason: This is incorrect because loss of depth perception is more consistent with a stroke involving
the right hemisphere. The right hemisphere controls visual-spatial perception, which includes depth perception, distance estimation, and object recognition. A stroke affecting this hemisphere can cause difficulty in navigating space, judging distances, and identifying objects.

Choice C reason: This is incorrect because the overestimation of abilities is more consistent with a stroke involving
the right hemisphere. The right hemisphere controls emotional regulation, self-awareness, and insight. A stroke affecting this hemisphere can cause euphoria, lack of insight, and unrealistic expectations.

Choice D reason: This is the correct answer because hemianopsia is consistent with a stroke involving
the left hemisphere. The left hemisphere controls language, logic, and analysis. A stroke affecting this hemisphere can cause hemianopsia, which is the loss of vision in half of the visual field. This can affect reading, writing, and communication skills.

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After completing a neurological assessment, the nurse documents that the client is stuporous. Which of the following describes this level of consciousness?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has suffered a traumatic brain injury. When the nurse applies a stimuli to the client, which of the following responses by the client indicates that the client has suffered an extensive cervical spine injury?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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