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 B

Explanation

A. This maneuver assesses shoulder strength and endurance but is not a direct measure of the normal range of motion. The test involves resistance but does not provide information on the full range of shoulder movement. It might reveal issues with muscle strength or endurance but does not effectively assess ROM.
B. This assessment technique evaluates shoulder flexion, where the client raises their arms straight up beside the ears, which is a key movement to measure in shoulder ROM. It assesses the ability to lift the arms fully overhead, which is an essential component of shoulder range of motion. This technique directly tests the normal ROM for shoulder flexion and abduction.
C. This maneuver tests coordination and proprioception rather than the range of motion. It is a test for the accuracy of movements and neurological function, particularly useful in assessing cerebellar function, but does not directly measure shoulder ROM.
D. This test assesses shoulder strength and stability rather than range of motion. It is useful for evaluating how well the shoulder can maintain a position but does not provide specific information about the range of motion in different directions.

A. Place the client in a standing position, leaning over the exam bed for inspection. B. Determine if the client uses any over-the-counter preparations for hemorrhoids. C. Position client in left lateral position to inspect perianal area for fissures or sacs. D. Ask the client how long she has experienced discomfort related to hemorrhoids.

Correct Answer is C

Explanation

A. A standing position leaning over the exam bed may not provide the best view or allow for thorough examination of the perianal area. This position is less commonly used and may not be ideal for a focused assessment of hemorrhoids.
B. Finding out if the client uses over-the-counter preparations for hemorrhoids provides useful information about the management and treatment approach being used. However, while this information is valuable, it does not directly involve the physical assessment of the hemorrhoids themselves.
C. The left lateral position (also known as the Sims' position) is commonly used for the examination of the perianal area. It provides optimal access for visual inspection of hemorrhoids, fissures, or other abnormalities in the anal region. This position allows the nurse to examine the area more thoroughly and comfortably, making it the most appropriate choice for a focused assessment of hemorrhoids.

D. Asking about the duration of discomfort provides valuable information about the history and progression of the condition. Understanding how long the client has been experiencing symptoms can help in assessing the chronicity and possible treatment history of the hemorrhoids.

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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

A client comes to the clinic due to shoulder discomfort and intermittent pain while swimming laps. To identify normal range of motion (ROM) of the client's shoulder, which assessment technique should the nurse ask the client to perform?

Correct Answer is B

Explanation

The nurse is assessing a female client who states that her hemorrhoids are inflamed and hurt constantly. Which intervention is best for the nurse implement to complete a focused assessment?

Correct Answer is C

Explanation

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