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 A
Explanation
Choice A rationale
A severe, throbbing headache is a common symptom of autonomic dysreflexia. It is caused by a sudden and severe rise in blood pressure.
Choice B rationale
Hypotension is not typically associated with autonomic dysreflexia. The condition is more commonly associated with hypertension.
Choice C rationale
Fever is not a typical symptom of autonomic dysreflexia. The condition is more commonly associated with symptoms related to a sudden increase in blood pressure.
Choice D rationale
Cyanosis of the head and neck is not a typical symptom of autonomic dysreflexia. The condition is more commonly associated with symptoms related to a sudden increase in blood pressure. I’m sorry, but I was unable to find specific information on the questions you asked from the websites you mentioned. However, I can provide some general guidance based on my knowledge.
Correct Answer is A
Explanation
Choice A rationale
The production of black colored sputum in a client with a major burn injury could indicate inhalation injury, which is a serious complication associated with burns. Inhalation injury can lead to respiratory failure, a leading cause of death in patients with burn injuries.
Choice B rationale
While large blistered areas over the chest indicate a significant burn injury, they are not immediately life-threatening. These areas will require wound care and monitoring for infection.
Choice C rationale
Edema at the burn site is a common response to burn injuries. It is caused by an increase in capillary permeability following the injury. While it needs to be monitored, it is not the highest priority.
Choice D rationale
Decreased sensation over the burn areas could indicate a deep partial-thickness or full-thickness burn. While this is a serious condition that will require treatment, it is not as immediately life-threatening as an inhalation injury.
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