Situation: Mr. Delmar, 70 years old, suddenly could not lift his spoon nor speak at breakfast. He was rushed to the hospital unconscious. His diagnosis is a cardiovascular accident (CVA).
- Which of the following is the most important assessment during the acute stage of an unconscious patient like Mr. Delmar? a. Level of awareness and response to pain b. Papillary re ilexes and response to sensory stimuli c. Coherence and sense of hearing d. Patency of airway and adequacy of respiration
- Considering Mr. Delmar’s condition, which of the following is most important to include in preparing Mr. Delmar’s bedside equipment? a. Hand bell and extra bed linen c. Footboard arid splint
c. Sandbag and trochanter rolls d. Suction machine and gloves
8. What is the rationale for giving Mr. Delmar frequent mouth care?
a. He will be thirsty considering that he is unable to take fluids
b. To remove dried blood when tongue is bitten during seizure
c. The tactile stimulation during mouth care will hasten return to consciousness
d. Mouth breathing in the case of most comatose patient causes oral mucosa to be dry and cracked
- One of the complications of prolonged bed rest is decubitus ulcer. Which of the following can BEST prevent is occurrence? a. Massage reddened areas with oil/lotion b. Turn patient frequently every 2 hours c. Use special water mattress d. keep skin clean and dry