The nurse observes a decrease in a client's level of consciousness. Which vital sign should the nurse obtain first?

Blood pressure.

Temperature.

Respiratory rate.

Pulse rate.

Answer and Explanation

The Correct Answer is C

Choice A: Blood pressure is not the first vital sign to obtain because it is not as sensitive to changes in the level of consciousness as respiratory rate. Blood pressure may be normal or elevated in some cases of decreased consciousness, such as stroke or head injury.

Choice B: Temperature is not the first vital sign to obtain because it is not as relevant to the level of consciousness as respiratory rate. Temperature may be normal or slightly elevated in some cases of decreased consciousness, such as infection or dehydration.

Choice C: Respiratory rate is the first vital sign to obtain because it reflects the adequacy of oxygenation and ventilation, which are essential for brain function. Respiratory rate may be increased, decreased, or irregular in cases of decreased consciousness, depending on the cause and severity.

Choice D: Pulse rate is not the first vital sign to obtain because it is not as indicative of the level of consciousness as respiratory rate. Pulse rate may be normal, fast, or slow in cases of decreased consciousness, depending on the cause and compensatory mechanisms.

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Correct Answer is C

Explanation

Choice A Reason: This is incorrect because occult blood is not visible to the naked eye. Waiting for observable blood may delay diagnosis and treatment of gastrointestinal bleeding.

Choice B Reason: This is incorrect because tarry black stool indicates upper gastrointestinal bleeding, which may not be related to the client's condition. Occult blood can be present in any color of stool.

Choice C Reason: This is correct because the nurse should obtain the specimen from the client's current bowel movement, regardless of its color or consistency. The test for occult blood detects hemoglobin in the stool, which may indicate bleeding anywhere along the gastrointestinal tract.

Choice D Reason: This is incorrect because contacting the healthcare provider before obtaining the specimen is unnecessary and may waste time. The nurse should follow the protocol for stool specimen collection and report any abnormal findings to the provider.

A. Nociceptive pain. B. Neuropathic pain. C. Acute pain. D. Visceral pain.

Correct Answer is ["B"]

Explanation

Choice A Reason: This is incorrect because nociceptive pain is caused by stimulation of nociceptors, which are sensory receptors that respond to tissue damage or inflammation. Nociceptive pain is usually localized and throbbing or aching.

Choice B Reason: This is correct because neuropathic pain is caused by damage or dysfunction of the nervous system. Neuropathic pain is usually diffuse and burning or shooting.

Choice C Reason: This is incorrect because acute pain is defined by its duration rather than its cause or quality. Acute pain lasts less than six months and usually has an identifiable cause and predictable course.

Choice D Reason: This is incorrect because visceral pain is caused by stimulation of nociceptors in the internal organs. Visceral pain is usually deep and cramping or squeezing.

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The nurse observes a decrease in a client's level of consciousness. Which vital sign should the nurse obtain first?

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Naxlex Comprehensive Predictor Exams

While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, solid, and light brown. Which action should the nurse implement?

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Explanation

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Correct Answer is ["B"]

Explanation

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