Which method should the nurse use to assess response to painful stimuli for a client with a marked reduction in the level of consciousness (LOC)?

Shake and call the client's name.

Press firmly on the center of the sternum.

Use aromatic spirits of peppermint.

Run a pointed object up the sale of foot.

Answer and Explanation

The Correct Answer is B

A.   Shaking the client and calling their name is generally used to assess responsiveness in clients who are not deeply unconscious but may be drowsy or semi-conscious. However, in clients with a marked reduction in LOC, this approach might not be effective because it does not provide sufficient stimulation to elicit a response from someone with significantly diminished consciousness.
B.   Applying firm pressure to the center of the sternum (sternal rub) is an effective method for assessing a client's response to painful stimuli, especially when there is a marked reduction in LOC. This technique involves using the knuckles to rub or press firmly on the sternum, which provides a strong and potentially painful stimulus to evaluate the client's responsiveness.
C.   Aromatic spirits of peppermint are used to stimulate a client's sense of smell but are not effective for assessing response to painful stimuli. This method is more suitable for clients who are semi-conscious and may respond to sensory stimulation but does not provide the level of stimulation needed for assessing deep unconsciousness.
D.   Running a pointed object up the sole of the foot is a method used to test the plantar reflex (Babinski reflex) and is not typically used to assess a response to painful stimuli. This method might be useful in neurological assessments but does not provide sufficient stimulation to assess responsiveness in a client with a marked reduction in LOC.

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Correct Answer is D

Explanation

A. Diminished short-term memory in older adults can be a sign of normal aging or early cognitive decline, such as mild cognitive impairment or early-stage dementia. While this is concerning, it is not typically an immediate indicator requiring urgent medical follow-up. It is important to monitor and assess memory changes over time, but it might not necessitate immediate action unless accompanied by other significant symptoms.
B. Reduced fine motor skills can occur due to aging, arthritis, or neurological conditions such as Parkinson's disease. While this finding is important for evaluating the client's functional status and quality of life, it does not usually require immediate medical follow-up unless it is sudden, severe, or accompanied by other alarming symptoms.

C. The Babinski reflex is a neurological test where stroking the sole of the foot causes the big toe to extend. In adults, a negative Babinski reflex (where the big toe does not extend) is normal and indicates that the corticospinal tract is functioning properly. A positive Babinski reflex is abnormal in adults and may indicate neurological damage.
D. A change in awareness of surroundings is a more urgent concern. It could indicate acute cognitive changes, delirium, or severe neurological issues that require prompt evaluation. Such changes can be related to various serious conditions, including infections, metabolic imbalances, or acute brain disorders.

A. Measure the degree of skin elasticity. B. Palpate the area for warmth and swelling. C. Determine the client's oxygen saturation. D. Observe the appearance of the nailbeds.

Correct Answer is B

Explanation

A. Skin elasticity is assessed by pinching the skin to see how quickly it returns to its normal position, which is often done to evaluate hydration status or the presence of dehydration. While skin elasticity is an important overall assessment of skin health, it is not directly related to the assessment of erythema.
B. Palpating the erythematous area for warmth and swelling is a crucial follow-up assessment. Erythema (redness of the skin) can be a sign of inflammation or infection, and the presence of warmth and swelling can help determine if the area is inflamed or if there might be an underlying infection.
C. Oxygen saturation measurements assess the level of oxygen in the blood, typically using a pulse oximeter. While oxygen saturation is important for assessing overall respiratory and circulatory health, it is not directly related to evaluating the cause or characteristics of erythema. Therefore, this would not be the most relevant follow-up assessment for a red area on the skin.
D. Observing the appearance of the nailbeds can provide information about overall circulation and oxygenation, but it is not directly related to assessing a localized area of erythema on the skin. Changes in the nailbeds can indicate systemic conditions but would not provide specific information about the erythematous area in question.

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Which method should the nurse use to assess response to painful stimuli for a client with a marked reduction in the level of consciousness (LOC)?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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