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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: A headache following a grade 1 concussion, while requiring monitoring, does not typically necessitate immediate proximity to the nurses' station. Grade 1 concussions are considered mild and usually do not involve loss of consciousness.

Choice B reason: A client who has experienced brain death and is awaiting organ procurement will not benefit from being close to the nurses' station due to the irreversible nature of brain death. The care for such a client is focused on maintaining organ viability for transplantation.

Choice C reason: A client with a score of 10 on the Glasgow Coma Scale following a motor vehicle crash should be placed closest to the nurses' station. A GCS score of 10 indicates a moderate level of impairment in consciousness and potentially unstable vital signs, requiring close monitoring and rapid nursing intervention.

Choice D reason: A score of 0 on the NIH Stroke Scale indicates no observable neurological deficit. Clients with a transient ischemic attack (TIA) and a score of 0 would require less intensive observation compared to those with higher scores or other acute neurological injuries.

A. Inject the medication into the abdomen above the level of the iliac crest. B. Use a 1-inch needle to inject the medication. C. Use a 25-gauge needle to inject the medication. D. Massage the injection site after administration of the medication.

Correct Answer is C

Explanation

Choice A reason: Injecting the medication into the abdomen above the level of the iliac crest is not recommended. The preferred sites for subcutaneous injections are the fatty tissue over the triceps, the abdomen from below the costal margin to the iliac crests, and the anterior aspects of the thighs. The area above the iliac crest may not have sufficient subcutaneous tissue, which could affect the absorption of the medication.

Choice B reason: Using a 1-inch needle can be appropriate depending on the client's body mass. For most adults, a 5/8-inch to 1-inch needle is recommended for subcutaneous injections to ensure the medication is delivered to the subcutaneous tissue and not into the muscle.

Choice C reason: Using a 25-gauge needle is the appropriate action when administering heparin subcutaneously. A smaller gauge needle, such as 25-gauge, is typically used for subcutaneous injections to minimize discomfort and tissue trauma.

Choice D reason: Massaging the injection site after administration of the medication is not recommended when administering heparin subcutaneously. Massaging the site can cause the medication to be absorbed more quickly than intended and may increase the risk of bleeding.

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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:

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Naxlex Comprehensive Predictor Exams

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