Fundamentals of Nursing
Quiz 30 :
In the given case, a 75-year-old woman was found unconscious on the floor and has been admitted in the hospital. She has been brought for her evaluation. Her vital signs are examined. The vital signs are within the normal range. She is awake now but can walk slowly. Her initial assessment is appropriate for the given client, once she gets admitted before starting any course of action or treatment. ________________________________________________________________________ During the initial assessment, the three systems that are to be assessed, which are of top priority for the unconscious client can be mentioned as follows: 1. The neurologic system : It helps to assess the client's physical, mental and behavioral state. The level of consciousness of the client can be determined by the response of the client in three major areas, such as the eye response, motor response and the verbal response. This helps to determine, whether the client is alert or in a coma. 2. The vital signs : It helps to detect the actual and potential health problems in the client. It includes the measurement of temperature, heart rate, respiration rate, blood pressure, and oxygen saturation. Some other measurements include height, weight, and blood sugar level. 3. The physical assessment : It helps to obtain the baseline data about the client's functional abilities, such as the sensor functioning, motor functioning, circulation, and disabilities. It allows the nurse to obtain the complete assessment of the client, including assessing the client's pupil for the reaction to light, if the patient is currently unconscious.
A nurses' job is to take care of the patient by two ways. By first going through the history of the patient, and secondly by doing a physical examination of the patient. A physical examination is comprised of three things, and out of these any one or two or all three can be performed at a single time. The first one is the complete assessment of the patient. This is done, when the patient is first admitted. The second one is examining certain body parts like the cardiovascular system (CVS). The third is the examination of the particular body area like the lungs. Tymphany is the sound that is heard on an air filled stomach. Hyper resonance is not a normal finding. Dullness is heard below the tenth intercostal space. Hence, the options 1, 3 and 4 are incorrect. A nurses' job is to take care of the patient by two ways. First by going through the history of the patient, and secondly, by doing a physical examination of the patient. Resonance is a normal sound heard over the left upper lobe of the lung. Hence, the correct answer is the option .
In the given case, a 75 year old woman was found unconscious on the floor and has been admitted in the hospital. She has been brought for evaluation and her vital signs are examined. Vital signs are within the normal range. She is awake now, but can walk slowly. Initial assessment is appropriate for the given client once she gets admitted before starting any course of action or treatment. Neurological assessment is essential for the given client, as she had altered level of consciousness. The client is awake, conscious and responsive to the environment. During the assessment of the client, she answered the questions with simple one-word answers or gestures. To assess the level of consciousness in the client, Glasgow Coma scale can be used. It is a scoring system used to describe the client's level of consciousness. The scale includes eye opening, motor response ad verbal response. In the given case, the verbal response of the client has been tested by asking questions and the client answered with single-words or gesture. It indicates that the client is awake and responsive to the voice, but is disoriented and confused. Thus, the score can be recorded as 4 for the verbal response. Measuring other two parameters in the scale gives a complete score. Total score of 7 or less indicates that client is in coma, while score of 15 indicates that client is alert and oriented.