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 C
Explanation
Choice A: Rinse your mouth with hydrogen peroxide
Rinsing the mouth with hydrogen peroxide is not recommended for clients with mucositis. Hydrogen peroxide can be too harsh and may cause further irritation to the already sensitive mucosal lining. It is generally advised to use mild rinses such as saline or baking soda solutions.
Choice B: Brush your teeth for 60 seconds twice daily
While brushing is important, it should be done gently with a soft-bristled toothbrush, and the timing should be based on patient tolerance rather than a strict 60-second rule.
Choice C: Floss your teeth gently following each meal
Gentle flossing helps remove food particles and bacteria, reducing the risk of infection. However, if bleeding occurs, the patient should stop and consult a healthcare provider.
Choice D: Wear your dentures only during meals
Wearing dentures only during meals might be advisable for some clients with mucositis, as wearing them all day could irritate the inflamed oral tissues. However, it’s important for the dentures to fit properly and for the client to have periods of rest without the dentures to allow the oral tissues to heal.
Correct Answer is D
Explanation
Choice A reason: A client with diabetes mellitus presenting with acute ketoacidosis does not necessarily require a private room unless there are other infection control concerns. Diabetic ketoacidosis (DKA) is a serious complication of diabetes that occurs when the body produces high levels of blood acids called ketones. It is a medical emergency that requires treatment in a hospital, but it is not contagious.
Choice B reason: An older adult client admitted with aspiration pneumonia would not typically require a private room solely based on this condition. Aspiration pneumonia is caused by inhaling food, stomach acid, or saliva into the lungs. It can lead to a bacterial infection, which may or may not be contagious depending on the causative organism.
Choice C reason: A client with a compound fracture of the right femur would not require a private room based on the diagnosis alone. A compound fracture, also known as an open fracture, is a fracture in which there is an open wound or break in the skin near the site of the broken bone. While it requires immediate medical attention to prevent infection, it is not a condition that necessitates isolation.
Choice D reason: A client who reports having fever, night sweats, and cough for 2 days may require a private room due to the possibility of an infectious disease that could be transmitted to others, such as tuberculosis (TB). These symptoms are concerning for TB, which is an airborne infectious disease and would require airborne precautions, including a private room with negative pressure ventilation.
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