A client who has sustained a head injury is being evaluated in the emergency room. The nurse performs a neurological assessment and notes that the client is somnolent. Which of the following describes an somnolent client response? Select all that apply.
An unconscious client is brought into the trauma bay after being “found down” in the community. There is no reportable history and no witnesses to any events leading up to the client being found. Which of the following tests would not be appropriate for the client in the immediate time period while in the client is in trauma bay?
A nurse is caring for a client who has experienced a head injury. The nurse is performing a focused neurological exam and documents that the client’s mental status is obtunded. Which best describes a client’s affect as obtunded?
The nurse is assigned to an older adult client in the emergency department whose family members report she is “acting bizarre”. The nurse notes a decreasing level of consciousness and confusion. The nurse obtains vital signs which are within normal limits. What is the nurse’s next priority?
The nurse recognizes that the client is suffering from acute delirium. What is the first action the nurse should take?
A client is brought to the trauma bay after a motor vehicle collision with rollover. The client is unconscious but breathing. On the neurological assessment, the client does not respond to his/her name. The nurse performs a sternal rub and the client’s eyes open, arms flex in no particular direction, and the client mumbles incoherently. The nurse anticipates the next action to be which of the following?
A nurse is helping a client to develop a sleep hygiene program to improve sleep habits. Which of the following would the nurse suggest for this client as part of sleep hygiene? Select all that apply.
A client has been diagnosed with REM sleep behavior disorder. Which of the following is associated with this type of sleep disorder? Select all that apply.
A client is dying and has become unconscious but is still breathing. While standing next to the client’s bed, his sister says, “I always wanted to tell him that I loved him, but it was so hard for me. Now it is too late.” Which response of the nurse is most appropriate?
A client who has suffered a head injury is brought in to the emergency department. Which question will allow the nurse to best determine if the client is alert and oriented?
