The nurse is caring for a client on a mechanical ventilator whose vital signs are T; 97.4°F oral; P: 112; R: 32; BP: 88/54

Question

The client has no spontaneous respirations, pupils are dilated and not responsive to light, EEG is flat, and the client has no reflexes. The client cannot be aroused, and has no response to stimulation. There has been no change in the client's condition for the past three days, and he is not receiving a controlled substance. The nurse recognizes that this client is: 1. Comatose.
2. In a vegetative state.
3. Brain-dead.
4. Obtunded.

Answer 1

3
Rationale: The client's flat EEG, lack of respirations, and dilated nonresponsive pupils indicate the brain is no longer functional and the client is dead, and is being kept alive by the mechanical ventilator. Comatose, vegetative, and obtunded clients do not have flat EEGs, and could have altered pupil response, but there would be some level of response.