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 C
Explanation
Choice A rationale
The femoral pulse is located in the groin area and is often used during procedures or when other pulse sites are not available. It does not directly assess circulation to the brain.
Choice B rationale
The radial pulse, located on the thumb side of the wrist, is commonly used to measure heart rate but does not directly assess circulation to the brain.
Choice C rationale
The carotid pulse is located on either side of the neck below the jawline. It is one of the major arteries that supply blood to the brain. In an emergency, this pulse site is used to assess circulation to the brain.
Choice D rationale
The popliteal pulse is located behind the knee and is used to assess circulation to the lower leg. It does not directly assess circulation to the brain.
Correct Answer is B
Explanation
Choice A rationale
Maintaining the client on bed rest is not a recommended intervention for a client with urolithiasis. Bed rest does not facilitate the passage of stones and can lead to complications such as deep vein thrombosis.
Choice B rationale
Encouraging the client to drink 3 L of fluids per day is the correct intervention. Increased fluid intake can help flush out the urinary system and facilitate the passage of stones. It also helps prevent new stone formation by diluting the substances that lead to stones.
Choice C rationale
Providing the client a high protein diet is not a recommended intervention for a client with urolithiasis. High protein diets can increase the amount of calcium and uric acid in urine, which can contribute to stone formation.
Choice D rationale
Telling the client to expect a decrease in urine output is not a recommended intervention for a client with urolithiasis. Decreased urine output can lead to urinary stasis and contribute to stone formation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.