While assessing an unconscious patient's neurologic status, the nurse applies pain by pinching the sternocleidomastoid muscle. Which statement by the nurse indicates an understanding of the use of this technique?
1. "Pain will make abnormal motor responses observable.".
2. "An unconscious patient's pain threshold is abnormally high.".
3. "Response to pain is an indicator of cognitive function.".
4. "The patient is most likely to respond to pain at that site.".
1
Rationale 1: In the unconscious patient, a painful stimulus such as the sternocleidomastoid pinch may elicit an observable abnormal motor response.
Rationale 2: The pain threshold of an unconscious patient is not necessarily high.
Rationale 3: Cognitive function is not tested by introduction of painful stimuli.
Rationale 4: It is the presence of pain, not its location, that is likely to elicit a response.
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