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 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.
Correct Answer is C
Explanation
Choice A rationale
A DNR prescription does not mean that the patient will only receive pain medication for their treatments. A DNR order simply means that if the patient’s heart stops beating or they stop breathing, medical staff will not attempt resuscitation3.
Choice B rationale
A DNR prescription does not necessarily limit a patient’s current treatment regimen. It only specifies that CPR will not be performed in the event of cardiac or respiratory arrest. Other treatments can still be provided based on the patient’s wishes and the medical team’s recommendations3.
Choice C rationale
A DNR prescription allows a patient to continue with their current treatment regimen. The DNR order only comes into effect if the patient’s heart stops or they stop breathing3.
Choice D rationale
While a DNR prescription may limit the ability to receive invasive procedures in the event of cardiac or respiratory arrest, it does not limit other forms of treatment. The patient can still receive treatments that align with their goals of care3.
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