The Unconscious Client

Question 1

Which clinical manifestations should the nurse expect to assess in a client diagnosed with an overdose of a cholinergic agent? SATA

1. dry mucous membranes
2. urinary incontinence
3. CNS depression
4. seizures
5. skin rash

Answer 1

2. urinary incontinence
3. CNS depression
4. seizures

Question 2

Which nursing action is a priority during the first 24 hours of hospitalization for a comatose client with suspected drug overdose?

1. Educate regarding drug abuse
2. Minimize pain
3. Maintain intact skin
4. Increase caloric intake

Answer 2

3. Maintain intact skin

Question 3

Which sign is an early indicator of hypoxia in the unconscious client?

1. cyanosis
2. decreased respirations
3. restlessness
4. hypotension

Answer 3

3. restlessness

Question 4

When administering intermittent enteral feeding to an unconscious client, what should the nurse do?

1. Heat the formula in a microwave
2. Place the client in a semi-Fowler’s position
3. Obtain a sterile gavage bag and tubing
4. Weight the client before administering the feeding

Answer 4

2. Place the client in a semi-Fowler’s position