Exam 68: Management of Comatose or Confused Clients

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

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

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 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.)

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

The nurse is aware that an infratentorial disorder will characteristically produce

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

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

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

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.)

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

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

A nurse explains that a major characteristic of delirium is

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

An elderly chronically confused client with Alzheimer's 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 client's perception is to

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

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

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

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

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