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

Answer and Explanation

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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Correct Answer is C

Explanation

A. A review of systems helps assess overall health and symptoms, but it may not always pinpoint the cause directly.
B. While this may be a part of the review of systems, the primary purpose is broader—identifying both current and past health problems.
C. The review of systems is designed to gather information on both current and past health problems, helping to form a comprehensive health history.
D. This is part of the process but is too narrow compared to identifying both current and past health concerns.

A. Alcohol consumption, obesity, diabetes, stress, and high cholesterol B. Personality type, high cholesterol, diabetes, and smoking C. Smoking hypertension, obesity, diabetes, and high cholesterol D. Family history, hypertension, stress, and age

Correct Answer is C

Explanation

A. While alcohol consumption and stress are risk factors, they are not as directly correlated to heart disease as smoking, hypertension, obesity, diabetes, and high cholesterol.
B. Although personality type is being explored as a risk factor, it is not as directly linked to heart disease risk as the factors listed in option C.
C. Smoking, hypertension, obesity, diabetes, and high cholesterol. These are well-established major risk factors for heart disease, directly impacting cardiovascular health.
D. Family history, hypertension, stress, and age. Family history, stress, and age can be risk factors, but the factors listed in option C are more direct and actionable in terms of management.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is interviewing a client in order to obtain a comprehensive health history. The purpose of a review of systems in the health history is to

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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