An adult admitted to the hospital after a stroke does not respond to verbal stimuli. What should the nurse do next to try to provoke a response?
a. Apply pressure to the mandible at the jaw.
b. Rub the patient's sternum.
c. Squeeze the trapezius muscle.
d. Gently shake the patient's shoulder.
D
If the patient does not respond to verbal stimuli, the nurse should try tactile stimuli by gently shaking the patient's shoulder. If the patient does not respond to tactile stimuli, the nurse should try painful stimuli by squeezing the trapezius muscle, rubbing the sternum, applying pressure on the mandible at the angle of the jaw, or applying pressure over the moon of the nail. But do not start out with painful stimulation before you are sure the patient is not going to react to a less invasive approach.
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