A patient is unresponsive to verbal stimuli and exhibits an altered level of consciousness.
Which method should the nurse use to elicit a response from a painful stimulus?
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 rationale
Pressing down on the orbital area of the eye is not typically used as it can cause injury to the eye.
Choice B rationale
Pinching the trapezius muscle is a common method used to elicit a response from a painful stimulus in an unresponsive patient. It is considered safe and effective.
Choice C rationale
Using a 25 gauge needle to elicit a response is not typically recommended as it can cause unnecessary harm to the patient.
Choice D rationale
Eliciting a reflex with a reflex hammer is not typically used to assess responsiveness to painful stimuli. Reflex hammers are primarily used to test reflexes, not responsiveness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Attaching the chest tube system to the foot of the bed is not recommended. This position could potentially cause the system to tip over or become disconnected, which could lead to complications such as pneumothorax or hemothorax.
Choice B rationale
The chest tube system should be placed below the level of the patient’s chest. This allows for gravity-assisted drainage of air and fluid from the thoracic cavity, which is crucial for the patient’s recovery. The system works on a water seal that prevents air or fluid from entering the pleural space. Placing the system below the chest level ensures that the water seal is maintained, preventing backflow of fluid or air into the pleural space.
Choice C rationale
Placing the system along the side of the patient’s knee is not appropriate. This position does not facilitate effective drainage of air and fluid from the thoracic cavity. It could also lead to discomfort and potential dislodgement of the system.
Choice D rationale
Placing the system at the level of the patient’s clavicle is not recommended. This position is too high and could disrupt the water seal, leading to ineffective drainage and potential complications.
Correct Answer is C
Explanation
Choice A rationale
Areas around pins being dry is a normal finding and does not need to be reported.
Choice B rationale
Crusts around pins are also a normal finding as they are usually dried exudate and do not indicate an infection.
Choice C rationale
Purulent drainage around pins is a sign of infection. This should be reported to the unit care coordinator immediately as it may require antibiotic treatment.
Choice D rationale
Absence of pain at the site is a normal finding and does not need to be reported.
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