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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Placing a pillow under the knees helps to relax the abdominal muscles and reduces tension during the abdominal examination.
B. Ensure adequate lighting - While good lighting is necessary for a thorough exam, it doesn't directly enhance muscle relaxation.
C. Expose the chest and abdomen for examination - Exposing the chest and abdomen is necessary for an abdominal exam but does not specifically aid in muscle relaxation.
D. Place the patient on their left side - This position is typically used for certain types of exams or procedures but does not specifically enhance muscle relaxation for an abdominal assessment.
Correct Answer is ["A","B","F"]
Explanation
A. Skin turgor refers to the elasticity of the skin, which can be affected by various conditions, including malignancy. The nurse should assess for any skin changes near the lump to identify any unusual signs.
B. The nurse should document the precise location of the mass, noting whether it is near the nipple or in another quadrant of the breast. This will help with future imaging and assessment.
C. While the history is important, it does not fall under objective findings that the nurse would document during the physical exam.
D. This is part of the patient’s history, not a direct observation during the physical exam, so it is not included in the documentation of objective findings of the breast mass.
E. Orientation refers to the patient’s mental status and does not relate to the characteristics of the breast mass.
F. The nurse should note the consistency of the mass (e.g., hard, firm, or soft). A firm, non-tender mass is often concerning for malignancy and should be documented.
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