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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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Varicosities, or varicose veins, are dilated veins that appear on the skin and are often associated with venous insufficiency. While they can be symptomatic and require management, they typically do not constitute an immediate medical emergency. Varicosities are generally managed with lifestyle changes, compression therapy, or medical procedures, but they are not usually life-threatening.
B. Lack of hair growth on the lower legs can indicate poor circulation, commonly seen in conditions like peripheral arterial disease (PAD). While it is a concerning finding and suggests potential arterial insufficiency, it is not usually an immediate emergency.
C. A Stage 2 pressure injury is characterized by partial-thickness loss of dermis, presenting as a shallow, open ulcer with a pink wound bed. While it requires attention to prevent progression and manage the wound, it is not an immediate emergency compared to other findings that suggest acute complications.

D. Right calf swelling and tenderness are critical findings that could indicate a deep vein thrombosis (DVT), which is a serious condition where a blood clot forms in a deep vein, usually in the leg. DVT can lead to life-threatening complications such as pulmonary embolism if the clot dislodges and travels to the lungs.

A. Wrist - able to bend wrist back toward forearm B. Elbow - only able to straighten joint 30 degrees

Correct Answer is {"A":{"answers":"D"},"B":{"answers":"B"}}

Explanation

Wrist: Able to bend wrist back toward forearm

Flexion: When the wrist bends back toward the forearm, it is an example of flexion. Flexion decreases the angle between the wrist and the forearm.

Elbow: Only able to straighten joint 30 degrees

Extension: The ability to straighten the elbow is indicative of extension. In this case, the client is only able to straighten the elbow to 30 degrees, which reflects limited extension.

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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)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing a client's lower extremities, which finding requires immediate intervention by the nurse?

Correct Answer is D

Explanation

Patient Data Exhibits

Correct Answer is {"A":{"answers":"D"},"B":{"answers":"B"}}

Explanation

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