In assessing a male client's level of consciousness, the nurse determines that the client does not open his eyes spontaneously. Which should the nurse do next?

Notify the healthcare provider.

Observe for eye opening to a painful stimulus.

Check the pupillary response to light.

Ask the client to open his eyes.

Answer and Explanation

The Correct Answer is B

A.   While notifying the healthcare provider is important if there are significant changes in the client's level of consciousness, it should not be the immediate next step. Before alerting the provider, the nurse needs to perform additional assessments to determine the extent of the client's unresponsiveness and gather more information about their neurological status.
B.   Observing for eye opening in response to a painful stimulus is a critical step in assessing the depth of unconsciousness. This response helps determine the client's level of consciousness and can provide information about the severity of their condition.
C.   Checking the pupillary response to light is important in evaluating neurological function and can provide information about brainstem activity and potential neurological deficits. However, it is secondary to checking for responses to stimuli like painful stimuli if the client is not opening their eyes spontaneously. Pupillary response should be assessed as part of a comprehensive neurological exam.
D.   Asking the client to open his eyes might not be effective if the client is unresponsive or has impaired consciousness. If the client is not responding spontaneously, it is likely that verbal commands will also be ineffective. This step is less useful when assessing levels of consciousness compared to more objective assessments like responses to painful stimuli.

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Correct Answer is C

Explanation

A. Hyperactive bowel sounds are not typically associated with gastroesophageal reflux disease (GERD). They are more indicative of gastrointestinal disturbances such as increased bowel activity or a bowel obstruction. Since the client's symptoms are related to heartburn, assessing bowel sounds is less relevant to GERD. This choice does not provide useful information for diagnosing or managing GERD.
B. This option is not commonly associated with GERD. In fact, small frequent meals are often recommended as a management strategy for GERD to reduce the occurrence of heartburn, as large meals can exacerbate symptoms by increasing stomach pressure. This choice does not align with typical GERD management strategies and may not be a useful symptom to assess in this context.
C. This finding is highly relevant for GERD. Heartburn that occurs or worsens when lying down, especially at night, is a classic symptom of gastroesophageal reflux disease. When a person lies flat, stomach acid can more easily flow back into the esophagus due to decreased gravitational pressure, leading to heartburn. Identifying this symptom helps confirm GERD and guides management strategies, such as elevating the head while sleeping or avoiding late meals.
D. Light grey and chalky stools are indicative of issues related to bile production and could suggest a problem with the liver or biliary system rather than GERD. This symptom is not associated with GERD and would be more relevant in assessing conditions such as biliary obstruction or liver disease.

A. Ask the client to swallow while palpating along the sides of the trachea. B. Palpate deeply and firmly over the location of the thyroid gland. C. Document that thyroid gland size is normal with no visible goiter. D. Defer the thyroid exam and observe the client for signs of myxedema.

Correct Answer is A

Explanation

A. Asking the client to swallow while palpating along the sides of the trachea helps in assessing the thyroid gland's size and mobility. The thyroid gland is located just below the larynx, and during swallowing, it moves upward, which can make it easier to palpate and identify any enlargement or nodules.
B. Palpating deeply and firmly might not be necessary and could be uncomfortable for the client. Gentle palpation is usually adequate for assessing the thyroid gland. Excessive force is not recommended as it may not yield additional information and could cause discomfort.
C. If the thyroid gland is not visible, documenting that it is normal without further assessment may not be accurate. The gland could be enlarged (goiter) or have other abnormalities that are not apparent on visual inspection alone. Accurate documentation should include findings from palpation and other assessment techniques.
D. Deferring the thyroid exam and focusing on signs of myxedema is not ideal in this situation. Myxedema is a severe form of hypothyroidism that can have various signs, but the immediate need is to assess the thyroid gland directly for goiter or other abnormalities. It is essential to perform a thorough examination and not rely solely on observation of symptoms that might appear later.

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In assessing a male client's level of consciousness, the nurse determines that the client does not open his eyes spontaneously. Which should the nurse do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse is assessing a client for goiter and is unable to observe the thyroid gland. Which action should the nurse take?

Correct Answer is A

Explanation

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