A nurse is caring for a client who is unconscious following a stroke. Which of the following nursing interventions is of highest priority?
Monitor the client's electrolyte levels.
Perform passive range of motion on each extremity.
Suction saliva from the client's mouth.
Record the client's intake and output.
The Correct Answer is C
A. Monitoring electrolyte levels is important but is not as immediate as ensuring airway patency.
B. Performing passive range of motion is beneficial for mobility but does not address the immediate needs of an unconscious patient.
C. Suctioning saliva from the client's mouth is the highest priority intervention, as maintaining airway clearance is critical to prevent aspiration and ensure adequate ventilation.
D. Recording intake and output is necessary for overall assessment but is not as urgent as managing the airway.
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Correct Answer is B
Explanation
A. The ascending tract of the spinal cord transmits sensory information to the brain, but it does not process it; processing occurs in the brain itself.
B. This statement accurately describes the function of the descending tracts, which carry motor commands from the central nervous system (CNS) to the muscles, facilitating movement.
C. Sensory receptors are located in various tissues throughout the body, including the skin, not just in the muscles.
D. Motor neurons are not found in the dermal layer; they are located in the spinal cord and the peripheral nervous system, where they innervate muscles.
Correct Answer is B
Explanation
A. Primary dementia is not characterized by temporary or reversible loss of brain function; it typically involves progressive and irreversible changes.
B. Forgetfulness that gradually progresses to disorientation is a common manifestation of primary dementia, indicating cognitive decline.
C. Hyper vigilant behaviors are not typical of dementia; instead, individuals may exhibit confusion or disorientation.
D. Sleeping more during the day than nighttime is not a specific manifestation of primary dementia and could be attributed to other factors, including other medical conditions or medications.