The nurse learns in report that a client is stuporous. Which assessment should the nurse perform to confirm this report?

Observe for any facial asymmetry.

Determine the response to stimuli.

Assess for a positive Romberg sign.

Check the pupillary response to light.

Answer and Explanation

The Correct Answer is B

A.   Facial asymmetry may indicate neurological issues, but it does not directly assess the stuporous state.
B.   A stuporous state is characterized by a reduced level of consciousness, and the nurse should assess
the client’s response to stimuli to confirm the report of stupor.
C.   A positive Romberg sign indicates a balance issue, but it is not directly related to confirming a stuporous state.
D.   While pupillary response is important, it does not provide sufficient information to confirm a stuporous state without assessing responsiveness to stimuli.

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Correct Answer is D

Explanation

A. This is a normal finding where the right pupil constricts when the light is directed at it, and the left pupil constricts consensually as well. This suggests normal function of the pupillary light reflex pathway, and no further evaluation is needed.
B. This also indicates normal pupillary function. Equal pupil size and appropriate constriction to light are typical findings, suggesting no immediate issues with the nervous system.
C. Pupil size should not change in response to distance unless there is a near response (accommodation). If the pupil size changes to distance of the light source instead of light reflex, this suggests potential abnormality in the pupillary reflex response.
D. This is an abnormal finding. A "notched" iris suggests possible damage or congenital anomalies, and minimal change in pupil size may indicate impaired pupil reflexes, requiring further evaluation to rule out neurological or ophthalmologic issues.

A. Tenting noted in subclavicular area. B. Loss of skin elasticity in the hand. C. Skin is warm and dry. D. Thinning hair in the lower extremities.

Correct Answer is A

Explanation

A. Skin tenting is a sign of dehydration. It occurs when the skin, after being pinched, does not quickly return to its normal position. This is often seen in areas with loose skin such as the subclavicular region.
B. Loss of skin elasticity is a normal aging process and not specifically indicative of dehydration. It can be seen in older adults regardless of hydration status.
C. Warm and dry skin can be a sign of dehydration. Dehydration leads to reduced sweating, which can result in dry skin, and it may also increase the body temperature, making the skin feel warm.
D. Thinning hair, especially in the lower extremities, is typically associated with circulatory issues or aging. It is not a direct sign of dehydration.

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The nurse learns in report that a client is stuporous. Which assessment should the nurse perform to confirm this report?

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Naxlex Comprehensive Predictor Exams

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