A patient is exhibiting an altered level of consciousness and is unresponsive to verbal stimuli. To elicit a response from a painful stimulus, the nurse would:
Press down on the orbital area of the eye.
Pinch the trapezius muscle.
Use a 25-gauge needle.
Elicit a reflex with a reflex hammer.
The Correct Answer is B
Choice A reason: Pressing down on the orbital area of the eye, known as the oculocephalic reflex or 'doll's eye' maneuver, is a method used to assess brainstem function in an unresponsive patient. However, this should be done with caution and is generally avoided if there is a suspicion of a neck injury or increased intracranial pressure.
Choice B reason: Pinching the trapezius muscle is a common method to elicit a response to painful stimuli. It is considered a less invasive and safer initial approach to assess the patient's response to pain without causing harm.
Choice C reason: Using a 25-gauge needle to elicit a response is not a standard practice and can be harmful. It poses a risk of skin puncture and infection, and it is not an appropriate method for assessing a patient's level of consciousness.
Choice D reason: Eliciting a reflex with a reflex hammer is used to assess the deep tendon reflexes, which can provide information about the integrity of the nervous system. However, it is not typically used as a method to elicit a response to painful stimuli in an unresponsive patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This statement encourages the client's involvement by offering assistance in creating a personalized list of preferred foods, which can then be discussed with the dietitian. It promotes a collaborative approach to the dietary plan, allowing the client to have a say in their food choices, which is essential for long-term adherence and management of type 2 diabetes.
Choice B reason: While this statement shows empathy, it does not actively encourage the client's involvement in their care. Understanding the challenges is important, but it is more beneficial to empower the client to take an active role in managing their dietary choices.
Choice C reason: This statement is factual, as managing diabetes does require accommodations. However, it does not directly encourage the client's involvement. Instead, it could be more encouraging by suggesting ways the client can participate in making those accommodations.
Choice D reason: Informing the client that the dietitian will provide the best food choices is reassuring but does not facilitate the client's involvement. It positions the dietitian as the sole decision-maker rather than including the client as an active participant in their dietary planning.
Correct Answer is D
Explanation
Choice A reason : Changing the transparent membrane dressing daily is not necessary unless it's soiled or compromised. The dressing is typically changed every 7 days or per institutional policy to reduce the risk of infection.
Choice B reason: Using a non-coring needle is not applicable for PICC lines as they are designed for use with a luer-lock syringe for medication administration and flushing.
Choice C reason : Maintaining a continuous IV infusion is not required for a PICC line unless clinically indicated. Intermittent use is common for medication administration, and the line should be flushed before and after use to maintain patency.
Choice D reason : Flushing the catheter with a 0.9% sodium chloride solution after each use is the correct action. This helps to maintain catheter patency and prevent occlusion.
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