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 B
Explanation
Choice A reason: Telling a family to limit discussing past events with the client may not be culturally sensitive. Each culture has its own views on reminiscing and sharing memories, especially during end-of-life care. Some cultures value the sharing of stories and memories as a way to honor the individual's life.
Choice B reason: Saying "We will respect what is important to you" is a statement that acknowledges and incorporates the client's and family's cultural beliefs. It shows a willingness to understand and prioritize their values, customs, and preferences in the care plan. This approach is aligned with culturally competent care, which is crucial in hospice settings.
Choice C reason: Offering to arrange all burial services may overstep boundaries, as burial practices are deeply rooted in cultural and religious beliefs. It is important for healthcare providers to discuss and understand the family's wishes and provide support in accordance with their specific cultural practices.
Choice D reason: Advising that grieving should not be done in front of the client may not align with the family's cultural beliefs about expressing emotions and grief. Different cultures have varied expressions of grief, and it is essential to respect these practices. Some cultures view the open expression of grief as an important part of the mourning process.

Correct Answer is C
Explanation
Choice A reason: The statement that a DNR prescription means the client will only receive pain medication is incorrect. A DNR (Do Not Resuscitate) order does not affect the provision of treatments other than those required to resuscitate the patient if their heart stops or they stop breathing. Patients with a DNR can still receive all other medical treatments and interventions aimed at managing symptoms and improving quality of life, including pain management.
Choice B reason: A DNR prescription does not limit the current treatment regimen in terms of ongoing treatments for the patient's condition. The DNR order specifically refers to not performing CPR (cardiopulmonary resuscitation) if the patient's breathing or heart stops. All other aspects of the patient's care plan, including aggressive treatments, can continue if they align with the patient's wishes and medical advice.
Choice C reason: This is the correct statement. A DNR prescription allows the patient to continue with their current treatment regimen. It is a directive that applies only in the event of cardiac or respiratory arrest, indicating that CPR should not be performed. However, it does not preclude the patient from receiving other medical treatments or interventions.
Choice D reason: A DNR prescription does not inherently limit the ability to receive invasive procedures. The decision to pursue or avoid invasive procedures would be based on the patient's overall treatment goals, prognosis, and personal preferences, not solely on the presence of a DNR order.
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