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 A

Explanation

A. In the context of detecting papilledema, "inspection" refers to using an ophthalmoscope to examine the optic disc for swelling. Papilledema, which is swelling of the optic disc due to increased intracranial pressure, can only be observed through this direct examination of the eye’s interior. This technique is the most appropriate and accurate for confirming papilledema as it allows the nurse to visually inspect the optic disc for signs of swelling or other abnormalities.
B. Percussion involves tapping on the body to assess underlying structures and is commonly used in evaluating lung and abdominal sounds. It is not used for assessing the optic nerve or papilledema. Therefore, percussion is not relevant for confirming the presence of papilledema.
C. Palpation involves feeling the body’s surface to assess for abnormalities such as swelling or
tenderness. It is used for evaluating various parts of the body but does not apply to detecting papilledema. Papilledema involves changes to the optic nerve head, which cannot be assessed through palpation.
D. Auscultation involves listening to internal body sounds using a stethoscope, such as heartbeats, lung sounds, or abdominal sounds. This technique is not used to assess the optic disc or detect papilledema. It is not relevant for the diagnosis of conditions affecting the optic nerve.

A. Ask the client to perform light exercise and observe the respiratory effort. B. Document "dyspnea on exertion" in the client's medical record. C. Ask the client to describe the episodes of dyspnea in more detail. D. Explain to the client the possible causes of dyspnea or "shortness of breath."

Correct Answer is C

Explanation

A. Performing light exercise may help in assessing how the client’s respiratory system responds to physical exertion and could reveal if the shortness of breath is related to activity. However, this action might not be appropriate if the client is currently asymptomatic or if the nurse needs more detailed information about the episodes of dyspnea.
B. Documenting "dyspnea on exertion" might be appropriate if the nurse has already confirmed that the shortness of breath occurs specifically with physical activity. However, based on the information provided, the nurse has not yet gathered sufficient details to confirm whether the dyspnea is related to exertion or another cause.
C. This option is the best initial action because it allows the nurse to gather detailed information about the nature, frequency, duration, and triggers of the client's shortness of breath. Understanding the context and specifics of the episodes will help in determining whether the dyspnea is related to underlying health issues, activity, or other factors.
D. While explaining the possible causes of dyspnea can be informative for the client, it may not address the immediate need for a detailed assessment of the client's symptoms. Providing education is valuable, but understanding the client's specific experience with dyspnea should take precedence to tailor the explanation and subsequent care effectively.

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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

Which assessment technique should the nurse use to confirm the presence of papilledema in a client with a rapidly decreasing level of consciousness?

Correct Answer is A

Explanation

While obtaining a health history, a client tells the nurse that he sometimes experiences shortness of breath. The nurse determines that the client's respirations are regular and deep, and his respiratory rate is 14 breaths/minute. What is the best nursing action?

Correct Answer is C

Explanation

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