The nurse is caring for a client whose recent health history includes an altered LOC. What should be the nurse's first action when assessing this client?

Assessing the client's verbal response.

Assessing the client's response to pain.

Assessing the client's judgment.

Assessing the client's ability to follow complex commands.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Assessing the client's verbal response is the first step in evaluating their level of consciousness (LOC). It provides immediate information about their ability to communicate and follow commands.

Choice B rationale

Assessing the client's response to pain is a later step in the LOC assessment if the client does not respond to verbal stimuli. It helps determine the level of consciousness if the client is not verbally responsive.

Choice C rationale

Assessing the client's judgment is part of a cognitive assessment but is not the first action when assessing LOC. It evaluates higher brain functions, not the initial level of responsiveness.

Choice D rationale

Assessing the client's ability to follow complex commands is part of a cognitive assessment and provides information about higher brain function but is not the first step in LOC assessment.

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Correct Answer is C

Explanation

Choice A rationale

A pustule is an elevated, round lesion filled with pus, not serum. Pustules are commonly seen in acne or infections.

Choice B rationale

A macule is a flat, discolored area of the skin that is not elevated. Macules do not contain fluid and are often seen in conditions like freckles or flat moles.

Choice C rationale

A vesicle is an elevated, round lesion filled with clear serum. Vesicles can result from conditions such as chickenpox, herpes simplex, or dermatitis.

Choice D rationale

A cyst is an elevated, round lesion filled with semi-solid material or fluid. Cysts are typically deeper in the skin compared to vesicles.

A. Temporal. B. Occipital. C. Frontal. D. Parietal.

Correct Answer is B

Explanation

Choice A rationale

Temporal lobe damage affects auditory processing and memory rather than visual stimuli interpretation, impacting functions like language comprehension and memory formation.

Choice B rationale

Occipital lobe is the primary visual processing center of the brain, responsible for interpreting visual stimuli. Damage to this lobe impairs visual perception and recognition, aligning with the symptoms described.

Choice C rationale

Frontal lobe injury affects executive functions, behavior, and motor skills, not visual stimuli interpretation. Symptoms include problems with planning, movement, and personality changes rather than visual processing issues.

Choice D rationale

Parietal lobe processes sensory information such as touch, temperature, and pain, and helps in spatial orientation. It does not primarily interpret visual stimuli, making it less relevant to the described visual interpretation difficulty.

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The nurse is caring for a client whose recent health history includes an altered LOC. What should be the nurse's first action when assessing this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During the skin assessment of a client, the nurse observes a skin lesion that is elevated, round, and filled with serum. Identify the type of lesion.

Correct Answer is C

Explanation

A client is diagnosed with a brain tumor. The nurse's assessment reveals that the client has difficulty interpreting visual stimuli. Based on these findings, the nurse suspects injury to which lobe of the brain?

Correct Answer is B

Explanation

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