Assessment of the client reveals that he is unresponsive to all stimuli and his eyes remain closed. The nurse documents the client's level of consciousness as which of the following?

Obtunded

Stupor

Coma

Lethargy

Answer and Explanation

The Correct Answer is C

A. Obtunded: Obtunded describes a state where a person has reduced alertness and is difficult to arouse but can respond to stimuli, such as verbal commands or physical touch. The client’s eyes remain closed and they are unresponsive to all stimuli, which is more severe than obtunded.
B. Stupor: Stupor is a condition where a person is in a near-unconscious state and responds only to vigorous or painful stimuli. Although the client is unresponsive to all stimuli, stupor usually involves some minimal response to pain or other strong stimuli, which doesn’t match the complete unresponsiveness described.
C. Coma: A coma is a profound state of unconsciousness where a person is unresponsive to all stimuli, including verbal, visual, and painful stimuli, and their eyes remain closed. This description matches the client’s condition of being unresponsive and with closed eyes.
D. Lethargy: Lethargy is characterized by excessive drowsiness or a reduced level of consciousness where the individual can be aroused with minimal effort. This state does not accurately describe a client who is unresponsive to all stimuli and whose eyes remain closed.

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Correct Answer is ["B","D","E"]

Explanation

A) Background: Orientation to "background" is not a standard component of the "AOX3" (alert and oriented times three) assessment. Typically, orientation assessments focus on more specific elements such as person, place, and time, rather than background information.
B) Person: Orientation to "person" means that the patient is aware of who they are. This is a key aspect of the AOX3 assessment, which checks whether the patient can identify themselves correctly.
C) Situation: While awareness of the situation or current circumstances is important, "situation" is not included in the standard AOX3 assessment. The usual components are person, place, and time.
D) Place: Orientation to "place" means the patient knows where they are. This is a critical component of the AOX3 assessment, indicating that the patient can identify their current location.
E) Time: Orientation to "time" means that the patient is aware of the current date, day of the week, and time of day. This is another essential part of the AOX3 assessment, reflecting the patient's awareness of the temporal context.

Correct Answer is "{\"xRanges\":[41.828125,50.828125],\"yRanges\":[132.5,141.5]}"

Explanation

The P wave is the first deflection of the ECG complex, preceding the QRS complex. It is typically a small, rounded, and positive deflection on the ECG.

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Assessment of the client reveals that he is unresponsive to all stimuli and his eyes remain closed. The nurse documents the client's level of consciousness as which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse reads in the patient chart the doctor's day round note. The doctor writes AOX3, the nurse knows this means the patient is oriented to: Select all that apply.

Correct Answer is ["B","D","E"]

Explanation

A nurse is teaching a newly licensed nurse about evaluating a cardiac rhythm. Which of the following options should the nurse identify as the P wave in the ECG complex? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Correct Answer is "{\"xRanges\":[41.828125,50.828125],\"yRanges\":[132.5,141.5]}"

Explanation

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