A client who recently had surgery is medicated prior to return to the nursing unit. Which assessment finding warrants the need for a more in-depth assessment when determining the client's score on the sedation scale?
1. The client is sleeping but is easy to arouse.
2. The client is somnolent, with minimal or no response to physical stimulation.
3. The client is slightly drowsy, but arouses easily with minimal physical stimulation.
4. The client is awake and alert visiting with family at the bedside.
Correct Answer: 2
The client who is somnolent, with minimal or no response to physical stimulation, requires further assessment with immediate action to reverse the cause. The other assessment findings are normal and do not require further assessment and treatment by the nurse.
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