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?

Observe for eye opening to a painful stimulus.

Ask the client to open his eyes.

Notify the healthcare provider.

Check the pupillary response to light.

Answer and Explanation

The Correct Answer is B

A. Observe for eye opening to a painful stimulus: Using a painful stimulus is part of the Glasgow Coma Scale (GCS) assessment for level of consciousness, providing a systematic way to determine the client's response level. This step should follow if the client does not respond to verbal commands.

B. Ask the client to open his eyes: This is a less invasive step that should be attempted first before applying a painful stimulus. It can provide immediate information about the client's level of consciousness and ability to follow commands.

C. Notify the healthcare provider: Notifying the healthcare provider is essential if the client's condition is critical or worsening. However, it should follow after initial assessment steps have been taken to determine the immediate status.

D. Check the pupillary response to light: Checking pupillary response is important for neurological assessment but does not directly address the need to evaluate the client's response to stimuli, which is critical for assessing consciousness levels.

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Correct Answer is D

Explanation

A. Ask questions in a vague, nonspecific format: Vague questions won't elicit clear answers.

B. Share personal values to put the client at ease: While building rapport is important, sharing personal values might not be necessary.

C. Get the most difficult questions over with first: This can make the client defensive and less likely to be honest.

D. Begin with less sensitive questions: Starting with general questions about lifestyle habits and then gradually transitioning to more specific questions about alcohol and substance use can create a more comfortable environment for open communication

A. Triceps skin fold and mid-arm circumference. B. Twenty-four-hour food recall, preferences, and allergies. C. Weight loss history and body surface area (BSA) D. Body mass index (BMI) and serum albumin level.

Correct Answer is D

Explanation

A. Triceps skin fold and mid-arm circumference. These measurements can provide some indication of nutritional status, but they may not be as reliable in older adults due to changes in body composition and skin elasticity.

B. Twenty-four-hour food recall, preferences, and allergies. While dietary information is important, it may not accurately reflect the client's current nutritional status.

C. Weight loss history and body surface area (BSA). While weight loss history is relevant, BSA is not typically used to assess nutritional status.

D. Body mass index (BMI) and serum albumin level. BMI is a commonly used indicator of nutritional status, and serum albumin level reflects protein status, which is important for assessing malnutrition.

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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

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