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: Administering prescribed corticosteroids is not the appropriate action for dyspnea associated with fluid overload from IV infusion. Corticosteroids are typically used to manage inflammatory conditions and are not indicated for this scenario.
Choice B reason: Slowing the infusion rate is the correct action when signs of fluid overload are present, such as dyspnea and hypertension. This helps to prevent further fluid accumulation. Contacting the provider is essential for further evaluation and management, which may include adjusting the fluid regimen or prescribing diuretics to manage the fluid overload.
Choice C reason: Lowering the head of the bed to a semi-Fowler's position may provide temporary relief for dyspnea but does not address the underlying issue of fluid overload. It is a supportive measure but should be accompanied by other interventions to manage the client's condition.
Choice D reason: Changing the infusion to lactated Ringer's would not address the issue of fluid overload and could potentially exacerbate the situation if the rate is maintained. The type of IV fluid is less important than the volume and rate of administration in the case of fluid overload.
Correct Answer is A
Explanation
Choice A reason: A client with type 1 diabetes mellitus who has taken a high dose of insulin is at significant risk for hypoglycemia. In type 1 diabetes, the body does not produce insulin, so insulin therapy is essential for controlling blood glucose levels. However, if the dose of insulin is too high relative to the patient's dietary intake or physical activity level, it can lead to a rapid decrease in blood glucose levels, resulting in hypoglycemia. Hypoglycemia is defined as a blood glucose level less than 70 mg/dL (3.9 mmol/L) and can cause symptoms such as confusion, sweating, weakness, and in severe cases, seizures or loss of consciousness.
Choice B reason: A client with type 2 diabetes who has not taken any medication may have elevated blood glucose levels but is not typically at immediate risk for hypoglycemia unless they are taking medications that lower blood glucose. Type 2 diabetes is characterized by insulin resistance, and while medication can help manage it, skipping medication does not usually result in hypoglycemia unless other factors are at play.
Choice C reason: An older adult client taking an antibiotic for an infection is not generally at risk for hypoglycemia unless the antibiotic interacts with other medications that the client is taking for diabetes management. Antibiotics themselves do not typically cause hypoglycemia.
Choice D reason: A client who has metabolic syndrome and is taking a statin drug to lower cholesterol levels is not at direct risk for hypoglycemia from the statin medication. Metabolic syndrome is a cluster of conditions that increase the risk for heart disease, stroke, and type 2 diabetes. While statins are used to lower cholesterol levels, they do not have a direct impact on blood glucose levels that would lead to hypoglycemia.
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