The nurse is caring for a patient whose recent health history includes an altered LOC. What should be the nurse's first action when assessing this patient?
A) Assessing the patient's verbal response
B) Assessing the patient's ability to follow complex commands
C) Assessing the patient's judgment
D) Assessing the patient's response to pain
Ans: A
Feedback:
Assessment of the patient with an altered LOC often starts with assessing the verbal response through determining the patient's orientation to time, person, and place. In most cases, this assessment will precede each of the other listed assessments, even though each may be indicated.
You might also like to view...
The nurse reviews the patient's laboratory results. What component of informatics is the nurse viewing?
a. Data b. Information c. Knowledge d. Wisdom
A client who has been diagnosed with breast cancer has many questions related to surgery, radiation
therapy, and chemotherapy. The nurse provides education about the disease and treatments but perceives that the client has further questions about coping with day-to-day situations. The action of greatest benefit to the client would be a. suggesting cognitive-behavioral therapy. b. teaching her to monitor her stress level. c. suggesting she enroll in a pain management program. d. referring her to a support group for individuals with breast cancer.
A woman asks her doctor what she can do before she begins trying to get pregnant to help her baby, since she is prone to anemia. The doctor correctly advises her to:
1. Get pregnant, then begin on extra iron. 2. Add more carbohydrates to her diet. 3. Begin taking folic acid supplements daily. 4. Have a hemoglobin baseline done now so her progress can be followed.
To reduce the risk of gallstones, clients could be advised to:
1. Eat breakfast 2. Limit fluid intake after supper 3. Eliminate fats from their diets 4. Add vinegar to cooked vegetables