When assessing a patient with altered level of consciousness, which of the following would the nurse assess first?
Respiratory status
Alertness
Motor response
Verbal response
The Correct Answer is A
Choice A: Respiratory status is the first priority, as it can affect the oxygenation and perfusion of the brain and other vital organs. The nurse should assess the rate, rhythm, depth, and quality of breathing, as well as the use of accessory muscles, chest expansion, and lung sounds.
Choice B: Alertness is not the first priority, but rather a component of the level of consciousness. The nurse should assess the patient's ability to open their eyes spontaneously or in response to stimuli, as well as their orientation to person, place, time, and situation.
Choice C: Motor response is not the first priority, but rather a component of the level of consciousness. The nurse should assess the patient's ability to move their limbs voluntarily or in response to stimuli, as well as their muscle strength, tone, and coordination.
Choice D: Verbal response is not the first priority, but rather a component of the level of consciousness. The nurse should assess the patient's ability to speak clearly and coherently, as well as their content and appropriateness of speech.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Encouraging lots of visitors is incorrect because it can increase the stimulation, stress, and noise level for the patient with a hemorrhagic stroke. A hemorrhagic stroke occurs when a blood vessel in the brain ruptures and bleeds into the surrounding tissue. This can cause increased intracranial pressure, brain damage, or death. The patient needs to rest and avoid any factors that can raise their blood pressure or worsen their condition.
Choice B: Out of bed with lots of walking in the halls is incorrect because it can also increase the risk of complications for the patient with a hemorrhagic stroke. The patient may have impaired mobility, balance, or coordination due to the brain injury. They may also have weakness, numbness, or paralysis on one side of the body. The patient needs to be assessed and assisted with their activity level and safety precautions.
Choice C: Nonstimulating, nonstressful environment; dim lighting, visitors are restricted is correct because it can help reduce the intracranial pressure and promote healing for the patient with a hemorrhagic stroke. The patient needs to have a quiet, calm, and comfortable environment that minimizes sensory input and emotional distress. The patient also needs to have limited and supervised visitors who are supportive and respectful of their needs.
Choice D: All of the above are incorrect because only choice c) is appropriate for the patient with a hemorrhagic stroke. Choices a) and b) are contraindicated and can harm or hinder the patient's recovery. The nurse should provide individualized and evidence-based care for the patient with a hemorrhagic stroke and follow the guidelines and protocols for stroke management.
Correct Answer is D
Explanation
Choice A: Dark quiet room is correct, as it can reduce the sensory stimulation and help the patient relax and rest.
Choice B: Massage is correct, as it can relieve muscle tension and improve blood circulation in the head and neck.
Choice C: Pain medication is correct, as it can reduce inflammation and block pain signals in the brain.
Choice D: All of the above is correct, as all of these interventions can help manage headache.
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