Deck 68: Management of Comatose or Confused Clients

Question 1

An elderly chronically confused client with Alzheimer's disease frequently states that the nursing home is her home to which she has invited people for a party. The most appropriate nursing response to this client's perception is to

A) give detailed explanations about the nursing home.
B) "go along" with the client's confused statements.
C) provide a lot of sensory stimulation.
D) reorient the client as often as necessary.

Answer 1

"go along" with the client's confused statements.

Question 2

The nurse points out the important difference between metabolically induced coma and structurally induced coma is that metabolically induced coma results in

A) abnormal posturing.
B) absent corneal reflex.
C) exaggerated deep tendon reflexes.
D) symmetrical motor manifestations.

Answer 2

symmetrical motor manifestations.

Question 3

When a client does not respond to verbal stimuli, to determine level of consciousness the nurse should

A) apply pressure across the client's nail bed.
B) ask the client to squeeze the nurse's fingers.
C) check deep tendon reflexes.
D) lightly pinch the skin of the hand.

Answer 3

apply pressure across the client's nail bed.

Question 4

Before the evacuation of a fecal impaction from a comatose client, the nurse applies an anesthetic jelly to the rectum in order to

A) decrease the risk of rectal tearing.
B) lessen the discomfort to hemorrhoids.
C) prevent possible seizures.
D) reduce discomfort of dislodging the fecal mass.

Question 5

The nursing action contraindicated in the care of a client with a severe basilar skull fracture is

A) nasal suctioning.
B) pharyngeal suctioning.
C) raising the head of his bed.
D) tooth brushing.

Question 6

A nurse preparing to give mouth care to a comatose client should first place this client into the position of

A) high Fowler.
B) lateral.
C) low Fowler.
D) prone.

Question 7

A nurse is assessing a client and considering the use of physical restraints to keep the client safe. In making this decision, which factors should the nurse consider? (Select all that apply.)

A) A goal is to use the least restrictive device for the shortest possible time.
B) Alternatives to restraint should be tried first as death and injury can occur.
C) How to communicate with the physician so an order is signed every 48 hours.
D) The frequency with which the client must be re-assessed.
E) The types and sizes of restraints the facility has available.

Question 8

A nurse is aware that when a client is admitted to the emergency department with coma of unknown origin, the most helpful laboratory study that may identify the cause is a

A) creatinine level.
B) glucose level.
C) hemoglobin level.
D) potassium level.

Question 9

When caring for an elderly client, the nurse should plan interventions based on the understanding that the elderly often

A) are frequently confused on admission.
B) are particularly at risk for confusion in the hospital.
C) do not seem bothered by changes in routines.
D) have an intact recent memory.

Question 10

The nursing action that is important to prevent complications from nasogastric feeding in a comatose client receiving tube feedings is to

A) check residual volume every 4 hours.
B) feed only small amounts every hour.
C) feed the client in the supine position.
D) stimulate the gag reflex every 8 hours.

Question 11

To improve the quality of sleep for a confused client, the nurse would plan to

A) allow for 90 minutes of undisturbed rest.
B) give warm black tea at bedtime.
C) keep the client awake during the day.
D) routinely use sedative medications.

Question 12

The nurse is aware that an infratentorial disorder will characteristically produce

A) a regular deep-breathing pattern.
B) abnormal pupillary response to light.
C) gradual unconsciousness.
D) predictive manifestations.

Question 13

A nurse explains that a major characteristic of delirium is

A) decline in social functions and sociability.
B) gradual onset and continuing decline.
C) multiple types of memory impairment.
D) reduced ability to focus, sustain, or shift attention.

Question 14

A nurse could appropriately assess for the doll's eye reflex in a client who is a/an

A) conscious man who has been diagnosed with acute cerebrovascular accident.
B) conscious young woman after an auto accident.
C) unconscious elderly man who has sustained a cervical spine injury.
D) unconscious teenager who has overdosed on drugs.

Question 15

The nurse cautions that the OVR test should not be used when assessing a client who exhibits

A) hypotension.
B) irregular respirations.
C) otorrhea.
D) vomiting.

Question 16

The nurse closely monitors the intake and output of a comatose client receiving hypertonic tube feedings because such feedings can cause

A) concentration of urine.
B) hypovolemia.
C) renal failure.
D) retention of fluid.

Question 17

The nurse assisting with the oculovestibular response (OVR) test on a client recognizes that the brain stem is intact when the client's eyes

A) demonstrate sustained nystagmus.
B) do not deviate with the instillation of ice water.
C) rapidly move toward the ear irrigated with warm water.
D) slowly move toward the ear irrigated with ice water.

Question 18

The nurse who is beginning oral feedings on a client who is returning to consciousness will

A) begin feedings with water.
B) place about 1 teaspoon of liquid in the front of the mouth.
C) position the client upright.
D) stroke the posterior neck to promote swallowing.

Question 19

The nurse will hyperoxygenate a comatose client before suctioning the airway to decrease the risk of

A) dysrhythmias.
B) hypotension.
C) infection.
D) seizure.

Question 20

The nurse working with an unconscious client to develop a holistic nursing care plan would include the family and which high-priority nursing diagnosis?

A) Anticipatory Grieving
B) Ineffective Therapeutic Regimen Management
C) Interrupted Family Processes
D) Knowledge Deficit

Question 21

A nurse is caring for a chronically confused client and family and has made the nursing diagnosis Caregiver Role Strain. Which action by the family would alert the nurse that outcomes are not being met? (Select all that apply.)

A) A support group schedule is noticed by the nurse in the spouse's pocket.
B) Children state the spouse has not seen old friends in several months.
C) The client's spouse states they cannot afford a bedside commode at home.
D) The family has arranged for mental competency testing for the client.

Question 22

The nurse caring for a client in restraints can delegate which of the following activities to an unlicensed assistive personnel? (Select all that apply.)

A) Assistance with ADLs
B) Massaging reddened areas under the restraint
C) Providing for food and elimination
D) Range of motion, both active and passive
E) Turning and repositioning