Chapter 68: Management of Comatose or Confused Clients Nursing School Test Banks

Black & Hawks: Medical-Surgical Nursing, 8th Edition

Test Bank

Chapter 68: Management of Comatose or Confused Clients

MULTIPLE CHOICE

1. The nurse points out the important difference between metabolically induced coma and structurally induced coma is that metabolically induced coma results in

a.

abnormal posturing.

b.

absent corneal reflex.

c.

exaggerated deep tendon reflexes.

d.

symmetrical motor manifestations.

ANS: D

Coma caused by a metabolic disorder more often is manifested as the presence of bilateral or symmetrical findings because the disorder affects the entire brain rather than just one section.

DIF: Comprehension/Understanding REF: p. 1794 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

2. A nurse is aware that when a client is admitted to the emergency department with coma of unknown origin, the most helpful laboratory study that may identify the cause is a

a.

creatinine level.

b.

glucose level.

c.

hemoglobin level.

d.

potassium level.

ANS: B

Immediate interventions for the client in a coma include treatment of common causes of coma while assessment of neurologic status and diagnostic testing continue. For example, after a blood specimen is drawn for testing, intravenous (IV) glucose is given to reverse potential insulin reactions.

DIF: Comprehension/Understanding REF: p. 1797 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

3. When caring for an elderly client, the nurse should plan interventions based on the understanding that the elderly often

a.

are frequently confused on admission.

b.

are particularly at risk for confusion in the hospital.

c.

do not seem bothered by changes in routines.

d.

have an intact recent memory.

ANS: A

It is a common misconception that the elderly naturally undergo a marked deterioration in mental function as they age. Remote memory may well be intact, but often the elderly have trouble remembering new information. The elderly rely heavily on familiar landmarks and established routines as cues to help them maintain independence. Admission to the hospital removes this assistance and this contributes to their vulnerability to confusion.

DIF: Comprehension/Understanding REF: p. 1809 OBJ: Intervention

MSC: Health Promotion and Maintenance Growth and Development Through the Lifespan-Age Related Differences

4. The nurse assisting with the oculovestibular response (OVR) test on a client recognizes that the brain stem is intact when the clients eyes

a.

demonstrate sustained nystagmus.

b.

do not deviate with the instillation of ice water.

c.

rapidly move toward the ear irrigated with warm water.

d.

slowly move toward the ear irrigated with ice water.

ANS: D

The OVR test uses the instillation of both cold and warm water to produce eye movement (toward the irrigated ear with ice water, away from the ear irrigated with warm water) to determine injury to the brain stem.

DIF: Analysis/Analyzing REF: p. 1796 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

5. The nursing action contraindicated in the care of a client with a severe basilar skull fracture is

a.

nasal suctioning.

b.

pharyngeal suctioning.

c.

raising the head of his bed.

d.

tooth brushing.

ANS: A

Never suction the nasal passages in the client with a basilar skull fracture or facial fractures because the suction catheter can enter the cranial cavity.

DIF: Application/Applying REF: p. 1799 OBJ: Intervention

MSC: Safe, Effective Care Environment Safety and Infection Control-Injury Prevention

6. The nursing action that is important to prevent complications from nasogastric feeding in a comatose client receiving tube feedings is to

a.

check residual volume every 4 hours.

b.

feed only small amounts every hour.

c.

feed the client in the supine position.

d.

stimulate the gag reflex every 8 hours.

ANS: A

Possible complications from enteral feeding include delayed gastric emptying and aspiration. Check residual volumes every 4 hours. If the residual volume is more than 100 ml, hold the feeding for 1 hour, and then resume. Feeding small amounts might not meet the clients nutritional needs. Feeding the client in the supine position would increase the risk of aspiration. Stimulating the gag reflex is not needed while the client is receiving enteral feedings. If the gag reflex needs to be checked, it should be done via a swallowing study administered by a speech therapist.

DIF: Application/Applying REF: p. 1802 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications of Diagnostic Tests/Treatments/Procedures

7. The nurse who is beginning oral feedings on a client who is returning to consciousness will

a.

begin feedings with water.

b.

place about 1 teaspoon of liquid in the front of the mouth.

c.

position the client upright.

d.

stroke the posterior neck to promote swallowing.

ANS: C

As consciousness returns and the client begins to respond to verbal stimuli and has a gag reflex, test the clients ability to suck and to swallow liquids. Before the test, position the client in high-Fowler position, and have suction equipment nearby in case it is needed. The nurse should use thickened juice or ice chips because these are easier to swallow than just water. The juice should be placed near the back of the mouth. Stroking the anterior, not posterior, neck can stimulate swallowing. This would be an intervention for a client with impaired swallowing as determined by a swallowing study.

DIF: Application/Applying REF: p. 1802 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications of Diagnostic Tests/Treatments/Procedures

8. Before the evacuation of a fecal impaction from a comatose client, the nurse applies an anesthetic jelly to the rectum in order to

a.

decrease the risk of rectal tearing.

b.

lessen the discomfort to hemorrhoids.

c.

prevent possible seizures.

d.

reduce discomfort of dislodging the fecal mass.

ANS: C

Clients with altered levels of consciousness need a daily bowel program that includes a regular schedule of stool softeners, suppositories, and performing digital removal of stool. However, stretching of the anus may cause seizures or an increase in intracranial pressure (ICP). A specific caution the nurse should incorporate into the plan of care is to use anesthetic jelly. The nurse should consult the physician before performing a digital removal of stool.

DIF: Analysis/Analyzing REF: p. 1804 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications of Diagnostic Tests/Treatments/Procedures

9. The nurse closely monitors the intake and output of a comatose client receiving hypertonic tube feedings because such feedings can cause

a.

concentration of urine.

b.

hypovolemia.

c.

renal failure.

d.

retention of fluid.

ANS: B

Hypertonic feeding can cause hypovolemia from hypertonic dehydration. The nurse should ensure the client receives 1 ml of water/1 kcal of feeding.

DIF: Application/Applying REF: p. 1802 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Fluid and Electrolyte Imbalances

10. An elderly chronically confused client with Alzheimers disease frequently states that the nursing home is her home to which she has invited people for a party. The most appropriate nursing response to this clients perception is to

a.

give detailed explanations about the nursing home.

b.

go along with the clients confused statements.

c.

provide a lot of sensory stimulation.

d.

reorient the client as often as necessary.

ANS: B

Clients with chronic confusion do not benefit from reorientation and actually become more agitated when the nurse attempts to reorient them. For these select clients, avoid reorienting and go along with the confusion.

DIF: Application/Applying REF: p. 1807 OBJ: Intervention

MSC: Psychosocial Integrity Psychosocial Adaptation-Sensory/Perceptual Alterations

11. A nurse could appropriately assess for the dolls eye reflex in a client who is a/an

a.

conscious man who has been diagnosed with acute cerebrovascular accident.

b.

conscious young woman after an auto accident.

c.

unconscious elderly man who has sustained a cervical spine injury.

d.

unconscious teenager who has overdosed on drugs.

ANS: D

The dolls eye test should never be performed in comatose clients with suspected or known cervical spine injury because the head movement required may produce permanent spinal cord damage. Since this is a test of brain stem function and is often used to support the suspicion of brain death, there would be no reason to perform it in a conscious person; in addition, conscious people have voluntary control over their eye movements and so the results would be invalid.

DIF: Application/Applying REF: p. 1796 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

12. When a client does not respond to verbal stimuli, to determine level of consciousness the nurse should

a.

apply pressure across the clients nail bed.

b.

ask the client to squeeze the nurses fingers.

c.

check deep tendon reflexes.

d.

lightly pinch the skin of the hand.

ANS: A

Check response to noxious stimuli. First, loud verbal stimuli and then shaking are performed to produce a response. If none is noted, the examiner applies a painful stimulus, such as pressure to the sternum, nail beds, or supraorbital notch. Care must be taken not to damage skin underlying the areas where pressure is applied. Hand squeezing may occur as a reflex and is best used to test for grip strength. Deep tendon reflexes are also a test of coma involvement, but do not take the place of response to stimuli. Pinching the skin of the hand might leave bruises and is not considered an appropriate method of applying noxious stimulation.

DIF: Application/Applying REF: p. 1797 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

13. The nurse will hyperoxygenate a comatose client before suctioning the airway to decrease the risk of

a.

dysrhythmias.

b.

hypotension.

c.

infection.

d.

seizure.

ANS: A

Hyperoxygenating the client before, between, and after suctioning decreases the risk of dysrhythmias.

DIF: Application/Applying REF: p. 1799 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications of Diagnostic Tests/Treatments/Procedures

14. A nurse preparing to give mouth care to a comatose client should first place this client into the position of

a.

high Fowler.

b.

lateral.

c.

low Fowler.

d.

prone.

ANS: B

When performing mouth care, place a comatose client in a lateral position to prevent aspiration.

DIF: Application/Applying REF: p. 1800 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications of Diagnostic Tests/Treatments/Procedures

15. The nurse working with an unconscious client to develop a holistic nursing care plan would include the family and which high-priority nursing diagnosis?

a.

Anticipatory Grieving

b.

Ineffective Therapeutic Regimen Management

c.

Interrupted Family Processes

d.

Knowledge Deficit

ANS: C

Interrupted Family Processes is an important nursing diagnosis for the family with an unconscious loved one. The family is often very stressed because of the uncertainty of the prognosis, the inability to communicate with the client, and experiencing various conflicting emotions.

DIF: Application/Applying REF: p. 1804 OBJ: Intervention

MSC: Psychosocial Integrity Coping and Adaptation-Family Dynamics

16. A nurse explains that a major characteristic of delirium is

a.

decline in social functions and sociability.

b.

gradual onset and continuing decline.

c.

multiple types of memory impairment.

d.

reduced ability to focus, sustain, or shift attention.

ANS: D

Three commonalities exist with all types of delirium: a disturbance of consciousness with a reduced ability to focus, sustain, or shift attention, that occurs over a brief period of time.

DIF: Comprehension/Understanding REF: p. 1805 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

17. To improve the quality of sleep for a confused client, the nurse would plan to

a.

allow for 90 minutes of undisturbed rest.

b.

give warm black tea at bedtime.

c.

keep the client awake during the day.

d.

routinely use sedative medications.

ANS: C

Plan nighttime interventions to allow 4 to 6 hours of uninterrupted sleep. Keep the client active during the day so that there is some fatigue by nighttime. Avoid the use of caffeinated beverages and alcohol, which may prevent sleep. Sleeping medications are seldom given to the confused client because they often alter sleep cycles and rob the client of rapid-eye-movement (REM) sleep.

DIF: Application/Applying REF: p. 1808 OBJ: Intervention

MSC: Physiological Integrity Basic Care and Comfort-Rest and Sleep

18. The nurse is aware that an infratentorial disorder will characteristically produce

a.

a regular deep-breathing pattern.

b.

abnormal pupillary response to light.

c.

gradual unconsciousness.

d.

predictive manifestations.

ANS: B

Infratentorial disorders have a sudden onset of unconsciousness, are not predictive, and produce abnormal breathing patterns and pupillary responses.

DIF: Comprehension/Understanding REF: p. 1794 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

19. The nurse cautions that the OVR test should not be used when assessing a client who exhibits

a.

hypotension.

b.

irregular respirations.

c.

otorrhea.

d.

vomiting.

ANS: C

Presence of otorrhea may indicate a ruptured tympanic membrane or a parietal skull fracture, which makes the caloric test both useless and possibly dangerous to the well-being of the client.

DIF: Comprehension/Understanding REF: p. 1796 OBJ: Intervention

MSC: Safe, Effective Care Environment Safety and Infection Control-Injury Prevention

MULTIPLE RESPONSE

1. A nurse is assessing a client and considering the use of physical restraints to keep the client safe. In making this decision, which factors should the nurse consider? (Select all that apply.)

a.

A goal is to use the least restrictive device for the shortest possible time.

b.

Alternatives to restraint should be tried first as death and injury can occur.

c.

How to communicate with the physician so an order is signed every 48 hours.

d.

The frequency with which the client must be re-assessed.

e.

The types and sizes of restraints the facility has available.

ANS: A, B, D, E

Using restraints is considered a high-risk intervention. The major goal is to use the least restrictive device for the shortest possible time. Alternatives to restraining a client must be attempted and documented. Each institution has its own policies for the frequency of re-assessment, and the nurse must be available to provide for nutrition, comfort, and elimination needs of the client, or can delegate these. Restraints must fit properly. A signed order is needed from the physician every 24 hours.

DIF: Analysis/Analyzing REF: pp. 1803, 1809

OBJ: Assessment

MSC: Safe, Effective Care Environment Safety and Infection Control-Use of Restraints/Safety Devices

2. The nurse caring for a client in restraints can delegate which of the following activities to an unlicensed assistive personnel? (Select all that apply.)

a.

Assistance with ADLs

b.

Massaging reddened areas under the restraint

c.

Providing for food and elimination

d.

Range of motion, both active and passive

e.

Turning and repositioning

ANS: A, C, D, E

Reddened areas under the restraint are immediately reportable by the unlicensed personnel to the registered nurse. All other options are activities the nurse can delegate.

DIF: Analysis/Analyzing REF: p. 1809 OBJ: Assessment

MSC: Safe, Effective Care Environment Management of Care-Delegation

3. A nurse is caring for a chronically confused client and family and has made the nursing diagnosis Caregiver Role Strain. Which action by the family would alert the nurse that outcomes are not being met? (Select all that apply.)

a.

A support group schedule is noticed by the nurse in the spouses pocket.

b.

Children state the spouse has not seen old friends in several months.

c.

The clients spouse states they cannot afford a bedside commode at home.

d.

The family has arranged for mental competency testing for the client.

ANS: C, D

Appropriate outcomes for this diagnosis include (1) improved use of support services, (2) obtaining adequate equipment to provide care, (3) limited use of addictive substances for coping, (4) interaction with friends and family as desired, and (5) appropriate analysis of the clients condition. Not seeing old friends in several months needs to be investigated further; it might be significant. Not being able to afford durable equipment is certainly an issue, but the clients spouse or family should investigate resources to help pay for this equipment.

DIF: Evaluation/Evaluating REF: p. 1808 OBJ: Assessment

MSC: Psychosocial Integrity Psychosocial Adaptation-Family Dynamics

Elsevier items and derived items 2009 by Saunders, an imprint of Elsevier Inc.

Some material was previously published.

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