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 A

Explanation

Choice A rationale
Handling the cast with the palms of the hands is recommended, especially when the cast is still wet and not fully hardened. This helps to avoid indentations and pressure points that could lead to discomfort or skin complications.
Choice B rationale
Drying the cast with a hair dryer is not typically recommended. Excessive heat can cause the cast material to weaken and can also burn the skin.
Choice C rationale
Keeping the casted leg in a dependent position is not recommended. This can lead to increased swelling and discomfort.
Choice D rationale
Covering the patient’s legs with a blanket is not specifically related to the care of a fresh cast. While it may provide comfort, it does not have a direct impact on the care or outcome of the cast.

A. A patient with type 1 diabetes who has taken a high dose of insulin. B. A patient with type 2 diabetes who has not taken any medication. C. An elderly patient who is taking an antibiotic for an infection. D. A patient with metabolic syndrome who is taking a statin to lower cholesterol levels.

Correct Answer is A

Explanation

Choice A rationale
A patient with type 1 diabetes who has taken a high dose of insulin is at the highest risk for developing hypoglycemia. Insulin lowers blood glucose levels, and taking a high dose can cause the levels to drop too low.
Choice B rationale
A patient with type 2 diabetes who has not taken any medication is not at a high risk for developing hypoglycemia. Without medication, their blood glucose levels may be high, not low.
Choice C rationale
An elderly patient who is taking an antibiotic for an infection is not at a high risk for developing hypoglycemia. Antibiotics do not typically affect blood glucose levels.
Choice D rationale
A patient with metabolic syndrome who is taking a statin to lower cholesterol levels is not at a high risk for developing hypoglycemia. Statins do not typically affect blood glucose levels.

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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 patient has recently had a cast applied to their left lower extremity. Which of the following is included in the nursing care of this fresh cast?

Correct Answer is A

Explanation

A nurse is providing care to multiple patients in a hospital setting. Which patient is at the highest risk for developing hypoglycemia?

Correct Answer is A

Explanation

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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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?