When a client does not respond to verbal stimuli, to determine level of consciousness the nurse should
a. apply pressure across the client's nail bed.
b. ask the client to squeeze the nurse's fingers.
c. check deep tendon reflexes.
d. lightly pinch the skin of the hand.
A
Check response to noxious stimuli. First, loud verbal stimuli and then shaking are performed to produce a response. If none is noted, the examiner applies a painful stimulus, such as pressure to the sternum, nail beds, or supraorbital notch. Care must be taken not to damage skin underlying the areas where pressure is applied. Hand squeezing may occur as a reflex and is best used to test for grip strength. Deep tendon reflexes are also a test of coma involvement, but do not take the place of response to stimuli. Pinching the skin of the hand might leave bruises and is not considered an appropriate method of applying noxious stimulation.
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