An adult client is admitted to the nursing unit with a medical diagnosis of Acute Stroke. The client does not respond to verbal stimuli. In this situation, what is the best action by the nurse to provoke a client response?
Apply pressure to the temporomandibular joint (TM)
Squeeze the trapezius muscle
Press hard on the client's sternum
Gently shake the client's shoulders
The Correct Answer is C
A. While pressure on the TM joint could stimulate a response, it is not the most appropriate method for provocation of a response in an unconscious or semiconscious client.
B. This action can be used to assess for painful stimuli, but pressing on the sternum is a more effective method for provoking a response in non-responding clients.
C. Applying firm pressure to the sternum, or sternal rub, is an effective technique to stimulate a response from clients who are non-responsive to verbal stimuli.
D. While shaking might be used for awakening a client, it is not as reliable or effective as a sternal rub when assessing neurological response in acute stroke patients.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Larger body size does not increase the risk for osteoporosis. In fact, individuals with a larger body may have more bone mass, offering some protection.
B. Although a history of fractures may indicate fragile bones, childhood fractures do not significantly contribute to the development of osteoporosis in adulthood.
C. Smoking is a well-established risk factor for osteoporosis. It reduces bone density and impairs bone regeneration, making smokers more prone to fractures and bone loss.
D. While excessive alcohol consumption can increase the risk of osteoporosis, consuming one alcoholic beverage per day is generally considered moderate and does not pose a high risk for osteoporosis by itself.
Correct Answer is D
Explanation
A. The trochlear nerve controls the superior oblique muscle of the eye and is not related to facial movements.
B. The abducens nerve controls the lateral rectus muscle of the eye, responsible for eye movement, not facial muscles.
C. The vagus nerve affects the soft palate, pharynx, and larynx, but does not contribute to facial expression.
D. Asymmetry in facial movements, like smiling, frowning, and puffing the cheeks, suggests dysfunction of the facial nerve (CN VII).
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