The patient is receiving neuromuscular blockade. Which nursing assessment indicates a target level of paralysis?
a. Glasgow Coma Scale score of 3
b. Train-of-four yields two twitches
c. Bispectral index of 60
d. CAM-ICU positive
B
A train-of-four response of two twitches using a peripheral nerve stimulator indicates adequate paralysis. The Glasgow Coma Scale does not assess paralysis; it is an indicator of consciousness. The Bispectral Index provides an assessment of sedation. The CAM-ICU is a tool to assess delirium.
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