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Comatose Client Assessment

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Questions and Answers

What is an expected finding in the physical appearance data collection?

Client looks younger than their stated age
Client is disheveled and unkempt
Client is wearing inappropriate clothing for the environment
Client is clean and dressed appropriately for the environment (correct)

Which abnormal posturing is associated with decerebrate rigidity?

Neck and elbow extension, wrist, and finger flexion (correct)
Twisting of the torso and limbs
Bending at the waist and neck
Flexion and internal rotation of upper extremity joints and legs

What does data collection for physical appearance include?

Personal hygiene, grooming, nutritional status, and clothing choice (correct)
Blood pressure and heart rate
Respiratory rate and oxygen saturation
Temperature and weight

What is the purpose of the Mini Mental State Examination (MMSE)?

To assess cognitive status and orientation to time and place (B) Signup and view all the answers

What does expected finding in physical appearance data collection NOT include?

Client looks older than their stated age (C) Signup and view all the answers

Which tool is used for pain rating?

Wong, Baker faces (A) Signup and view all the answers

Who can provide valuable information for data collection in mentally healthy children and adolescents?

Both the client and caregivers (C) Signup and view all the answers

What is the purpose of physical examination in mental health nursing?

To assess the client's physical condition and collect data (C) Signup and view all the answers

Why should the nurse ask for feedback from the client after an interview?

To summarize the interview findings for record-keeping (A) Signup and view all the answers

What is the primary concern when performing physical data collection for a client in mental health nursing?

Using physical examination to assess and collect data on the client's condition (C) Signup and view all the answers

What is a possible consequence of not asking for the client's feedback after an interview?

Inability to understand the client's perception of illness and wellness (C) Signup and view all the answers

What should the nurse do if the client is triggered by touch during physical examination?

Immediately stop the physical examination to avoid further triggering (A) Signup and view all the answers

Which action best demonstrates cultural sensitivity in mental health nursing?

Incorporating the client's cultural beliefs into the care plan (A) Signup and view all the answers

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