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.

Answer and Explanation

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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Correct Answer is D

Explanation

Choice A rationale
Assisting the client to sit upright in a chair for 4 hr at a time is not recommended postoperatively following spinal fusion. This could put undue stress on the surgical site and potentially lead to complications.
Choice B rationale
Expecting clear drainage on the spinal dressing is not accurate. Any drainage from the surgical site should be closely monitored for signs of infection, but clear drainage is not typically expected.
Choice C rationale
Elevating the client’s legs when he is lying on his side is not a specific intervention related to postoperative care following spinal fusion.
Choice D rationale
Log rolling the client every 2 hr is the correct intervention. This technique is used to maintain proper alignment and prevent undue stress on the surgical site.

A. Hypertension B. Purpura C. Bradypnea D. Oliguria

Correct Answer is D

Explanation

Choice A rationale
Hypertension is not typically associated with hypovolemic shock. In fact, hypotension, or low blood pressure, is more common.
Choice B rationale
Purpura, or blood spots, are not typically associated with hypovolemic shock.
Choice C rationale
Bradypnea, or slow breathing, is not typically associated with hypovolemic shock. Rapid, shallow breathing is more common.
Choice D rationale
Oliguria, or decreased urine output, is a common finding in hypovolemic shock. It occurs due to decreased blood flow to the kidneys.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the plan of care for a client who is 1 day postoperative following spinal fusion. Which of the following interventions should the nurse include in the plan?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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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?