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