The nurse is caring for a patient whose recent health history includes an altered level of consciousness. What should be the nurse’s initial action when assessing this patient?

Assessing the patient’s ability to follow complex commands

Assessing the patient’s judgment

Assessing the patient’s verbal response

Assessing the patient’s response to pain

Answer and Explanation

The Correct Answer is D

Choice D rationale
When assessing a patient with an altered level of consciousness, the nurse’s initial action should be to assess the patient’s response to pain. This is a fundamental part of the neurological examination and can provide valuable information about the patient’s level of consciousness and neurological function. Pain response can be assessed by applying a painful stimulus, such as a pinch, and observing the patient’s reaction.
Choice A rationale
Assessing the patient’s ability to follow complex commands is an important part of the neurological examination, but it is not typically the initial action when assessing a patient with an altered level of consciousness. This assessment requires a higher level of cognitive function and may not be possible in a patient with significantly altered consciousness.
Choice B rationale
Assessing the patient’s judgment is an important part of the mental status examination, but it is not typically the initial action when assessing a patient with an altered level of consciousness. Like the ability to follow complex commands, judgment requires a higher level of cognitive function and may not be assessable in a patient with significantly altered consciousness.

Choice C rationale
Assessing the patient’s verbal response is an important part of the neurological examination, but it is not typically the initial action when assessing a patient with an altered level of consciousness. The patient’s ability to speak and the content of their speech can provide important information about their neurological function, but this assessment may not be possible in a patient with significantly altered consciousness.

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Correct Answer is A

Explanation

Choice A rationale
For a client with Parkinson’s disease who has difficulty swallowing or chewing due to muscle rigidity, semi-solid food with thick liquids can be easier to swallow and reduce the risk of choking19.
Choice B rationale
Minced foods and fluid restriction may not provide the necessary nutrients and hydration for a client with Parkinson’s disease19.
Choice C rationale
A low-residue diet, which is low in fiber, may not be appropriate for a client with Parkinson’s disease, as constipation is a common symptom of the disease and fiber can help alleviate this19.
Choice D rationale
Total parenteral nutrition (TPN) is a method of feeding that bypasses the gastrointestinal tract. It is typically reserved for clients who cannot or should not get their nutrition through eating19.

A. Encourage participation in multiple-step activities B. Promote hobbies involving fine motor skills C. Limit visitors to one or two at a time D. Promote frequent lengthy visits from friends . .

Correct Answer is C

Explanation

Choice A rationale
While participation in multiple-step activities can provide mental stimulation, it may be challenging for a patient with Alzheimer’s disease. These activities often require a level of cognitive functioning that may be impaired in Alzheimer’s patients. As a result, these activities could lead to frustration and agitation rather than fostering socialization.
Choice B rationale
Hobbies involving fine motor skills can be beneficial for maintaining dexterity and coordination. However, as Alzheimer’s disease progresses, these skills often decline. Therefore, while these hobbies may be enjoyable, they may not necessarily foster socialization.
Choice C rationale
Limiting visitors to one or two at a time can help to prevent overstimulation, which can be distressing for a person with Alzheimer’s disease. Smaller, more intimate gatherings can also foster more meaningful social interactions. Therefore, this approach can be beneficial for promoting socialization.
Choice D rationale
While social interaction is important for people with Alzheimer’s disease, frequent lengthy visits from friends may be overwhelming and lead to fatigue. It’s important to balance socialization with rest and relaxation. Therefore, promoting frequent lengthy visits may not be the best approach to foster socialization.

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The nurse is caring for a patient whose recent health history includes an altered level of consciousness. What should be the nurse’s initial action when assessing this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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