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1. Question
The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client’s peripheral response to pain?
Correct
Answer & Rationale:
Option 2 is Correct
Rationale: Motor testing in the unconscious client can be done only by testing response to painful stimuli. Nail bed pressure tests a basic peripheral response. Cerebral responses to pain are tested using a sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.
Incorrect
Answer & Rationale:
Option 2 is Correct
Rationale: Motor testing in the unconscious client can be done only by testing response to painful stimuli. Nail bed pressure tests a basic peripheral response. Cerebral responses to pain are tested using a sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.
THE UNCONSCIOUS CLIENT
Description
The unconscious client is in a state of depressed cerebral functioning with unresponsiveness to stimulation of sensory and motor function.
Some causes include head trauma, cerebral toxins, shock, hemorrhage, tumor, and infection.
