To evaluate the patient’s level of Consciousness (LOC), the nurse will:
Check turgor.
Check for pupillary response.
Observe for awake and alertness.
Auscultate temporal artery.
The Correct Answer is B
Pupillary response is one of the important indicators of a patient's level of consciousness (LOC). The nurse can observe the size, shape, and reaction of the patient's pupils to light. The pupils should be equal in size, round, and reactive to light. Any abnormalities in the pupils, such as unequal size or lack of reaction to light, may indicate an altered LOC and require further evaluation by a healthcare provider.
Checking turgor, observing for awake and alertness, and auscultating the temporal artery are not specific assessments for evaluating a patient's LOC. Turgor is used to assess for dehydration, observing for awake and alertness is a general assessment of the patient's mental status, and auscultating temporal artery is used to assess for temporal artery pulse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Prostate enlargement is not directly assessed through an anal examination.
Correct Answer is A
Explanation
When assessing the abdomen, the nurse would expect to auscultate bowel sounds, which are the sounds made by the movement of gas and fluid through the intestines. The normal bowel sounds are characterized as high-pitched, gurgling, and occurring at a rate of 5-30 sounds per minute.
Bruits are abnormal sounds indicating turbulent blood flow and are usually assessed in other areas of the body, such as the epigastric and renal arteries, as well as in the aorta.
Friction rubs are also abnormal sounds, but they are typically heard during auscultation of the heart and lungs.
Low-pitched sonorous sounds are not typical sounds that are expected to be heard during an abdominal assessment
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