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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Related Questions
Correct Answer is D
Explanation
A. Dry mouth (xerostomia) may occur after a stroke, but it is not the most likely symptom when there is facial drooping, which suggests more significant swallowing and motor function issues.
B. Rhinorrhea (runny nose) is not directly associated with a stroke and would not typically be expected in this scenario.
C. Dysphagia (difficulty swallowing) is a common finding in patients who have suffered a stroke, particularly when there is facial drooping or difficulty with facial muscle control.
D. Nosebleeds are not directly linked to stroke symptoms and are unlikely to be caused by the facial drooping.
Correct Answer is C
Explanation
A. This is incorrect, as a patient’s expression of pain can vary significantly based on cultural, emotional, and psychological factors, not just the severity of the injury.
B. This is false. Pain expression is highly individualized and influenced by cultural and personal factors.
C. This is correct. Different cultures and individuals have varied ways of expressing pain, which can affect their pain management.
D. This is not accurate. Cultural norms play a significant role in how individuals tolerate and express pain.
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