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.
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Related Questions
Correct Answer is B
Explanation
Choice A rationale
Gastroesophageal reflux disease (GERD) is a chronic condition where stomach acid frequently flows back into the esophagus, irritating the lining and causing symptoms like heartburn. Protonix (pantoprazole) is a proton pump inhibitor that decreases the amount of acid produced in the stomach. While it is used to treat GERD, it is not typically used prophylactically in trauma patients.
Choice B rationale
Stress ulcers are a type of peptic ulcer that is particularly common in critically ill or severely stressed patients, such as those with severe trauma like an automobile accident. These ulcers occur when the body’s physical stress leads to increased gastric acid secretion, which can damage the gastric mucosa and lead to ulcers. Protonix, by reducing stomach acid, can help prevent these ulcers in high-risk patients. This is why it is often administered prophylactically in severe trauma cases.
Choice C rationale
Dumping syndrome is a condition that can occur after surgery to remove all or part of your stomach or after surgery to bypass your stomach to help you lose weight. It’s also known as rapid gastric emptying. Protonix is not typically used to prevent dumping syndrome.
Choice D rationale
Gastritis is an inflammation of the stomach lining. While Protonix can be used to treat gastritis, it is not typically used prophylactically for this condition in trauma patients.
Correct Answer is A
Explanation
Choice A rationale
Furosemide is a diuretic, or water pill, that helps your body get rid of extra salt and water. It can cause you to lose too much potassium, a mineral that helps your nerves, muscles, and organs work normally. So, it’s important to eat foods that are high in potassium, such as bananas, oranges, tomatoes, beans, and spinach.
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