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 B

Explanation

Choice A rationale
The Trendelenburg position, which involves laying the patient flat on their back with their legs elevated higher than their head, is not recommended for patients with septic shock. This position can increase intracranial pressure and does not improve circulation or oxygenation.
Choice B rationale
Changing the patient’s position slowly is important in managing an elderly patient with septic shock. Rapid changes in position can cause a drop in blood pressure (orthostatic hypotension), which can lead to falls or decreased perfusion to vital organs.
Choice C rationale
Reducing the oxygen flow is not recommended for patients with septic shock. These patients often have difficulty with oxygenation and may require supplemental oxygen to maintain adequate oxygen levels.
Choice D rationale
Increasing the IV fluid flow is part of the initial management of septic shock to restore perfusion, but it should be done based on careful assessment and monitoring of the patient’s response to fluids. Overzealous fluid resuscitation can lead to fluid overload and complications such as pulmonary edema.

A. Reports pain at burn site B. Hands are edematous C. Burned area has a foul odor D. Temperature is 99.8 degrees Fahrenheit .

Correct Answer is C

Explanation

Choice A rationale
While pain at the burn site can be a symptom of many conditions, it is not a specific indicator of a local infection in the burned area.
Choice B rationale
Edematous hands can be a sign of many conditions, including burns, but they are not a specific indicator of a local infection in the burned area.
Choice C rationale
A foul odor from the burned area is a strong indicator of a local infection. Bacteria and other microorganisms that cause infections can produce waste products that have a foul smell.
Choice D rationale
A temperature of 99.8 degrees Fahrenheit is within the normal body temperature range and is not a specific indicator of a local infection in the burned area.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for an 85-year-old patient with septic shock. What should the nurse consider when repositioning this patient?

Correct Answer is B

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When caring for a patient with burns, which assessment data will alert the nurse to the possibility of a local infection of the burned area?

Correct Answer is C

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?