Neurological Question #15

Question

The nurse is assessing the central stimulus function of an unconscious client in the intensive care unit. The nurse should plan to use which technique to test the client’s central response to stimuli?

Answers

  1. Supraorbital ridge pressure.
    • Rationale:
  2. Sternal rub.
    • Rationale:
  3. Pressure on the nail bed.
    • Rationale:
  4. Calling out loudly close to the client’s ear.
    • Rationale:

Overview

Explanation

Central stimulus is applied to cranial nerves not peripheral nerves. Supraorbital ridge pressure by applying pressure on the orbital rim is indicated for central stimulus assessment. Sternal rub is usually not indicated via best practices. Pressure on the nail bed represents testing painful stimuli for motor testing on peripheral nerves. Calling out loudly is not an assessment technique for central stimulus function. There are two anatomic locations for pain stimulus: centrally and peripherally. Central involves trapezious pinch or supraorbital pressure whereas peripheral stimuli are applied to extremities. Responses may infer damage to the brain or specific brain areas.

Learning Outcomes

Test Taking Tip

Video Rationale