While Assessing an Unconscious Patient's Neurologic Status, the Nurse Applies

question 16

Multiple Choice

While assessing an unconscious patient's neurologic status, the nurse applies pain by pinching the sternocleidomastoid muscle. Which statement by the nurse indicates an understanding of the use of this technique?

• A) "Pain will make abnormal motor responses observable."
• B) "An unconscious patient's pain threshold is abnormally high."
• C) "Response to pain is an indicator of cognitive function."
• D) "The patient is most likely to respond to pain at that site."