The intensive care nurse plans to test nociception in the patient with a closed-head injury. Which of the following actions by the nurse will complete this assessment?
1. asking the patient to squeeze and release the nurse's hand
2. placing a strong scent close to the patient's nostrils
3. observing the patient's pupils as an object is moved in the visual fields
4. pressing the patient's nailbed and observing the patient's reaction
4
Rationale: Nociception refers to the activation of pain receptors to the point of pain. Pressing the patient's nailbed can elicit a motor response to pain that provides evidence of nociception. Squeezing and releasing the nurse's hand on command provides neurological assessment data; however, this action should not be painful to the patient. Assessing sense of smell and ocular movements will not provide nociception data.
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