The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain?

Correct Answer: B

Rationale: The correct answer is B: Nail bed pressure. This is the appropriate method to test the client's peripheral response to pain in an unconscious state. Applying pressure to the nail bed can elicit a localized pain response, indicating intact peripheral nerve function. Rationale: 1. Nail bed pressure is a sensitive area that can evoke a pain response if the client has intact peripheral nerve function. 2. Sternal rub (A) is a sternal pressure technique used to arouse a client, not specifically to test peripheral response. 3. Pressure on the orbital rim (C) is not appropriate for testing peripheral response and can be harmful. 4. Squeezing the sternocleidomastoid muscle (D) is a method to assess cranial nerve XI function, not peripheral response to pain.

Correct Answer: A

Rationale: The correct answer is A: Hypertonicity. In Parkinson's disease, there is a loss of dopamine-producing cells, leading to increased muscle tone or hypertonicity. This results in stiffness and rigidity of muscles, making movements slow and difficult. Hypotonicity (B) refers to decreased muscle tone and is not typically seen in Parkinson's. Hyperreflexia (C) is an exaggerated reflex response, which is not a common feature of Parkinson's. Hyporeflexia (D) is reduced reflex response, which is not typically associated with Parkinson's disease. Hence, the most likely clinical finding in a patient with Parkinson's disease would be hypertonicity.

Correct Answer: D

Rationale: The correct answer is D: Prevent pulmonary complications. Using an incentive spirometer post-thoracic surgery helps prevent atelectasis and pneumonia by promoting lung expansion, improving ventilation, and clearing secretions. This intervention aids in maintaining lung function and preventing respiratory complications. A: Promote relaxation - While using an incentive spirometer may induce relaxation as a side effect, the primary purpose is not relaxation but rather to prevent pulmonary complications. B: Improve inspiratory muscle strength - Although using an incentive spirometer can help improve inspiratory muscle strength, the primary purpose is to prevent pulmonary complications. C: Reduce pain during breathing - While using an incentive spirometer may indirectly reduce pain by promoting optimal lung function, the primary purpose is to prevent pulmonary complications.

Correct Answer: B

Rationale: The correct answer is B: Silver sulfadiazine dressing. This choice is correct because silver sulfadiazine has antimicrobial properties that can help prevent infection in deep partial-thickness burns. It also provides a moist environment for wound healing. A: Hydrocolloid dressing is not ideal for deep partial-thickness burns as it may not provide enough antimicrobial protection. C: Gauze dressing with saline is not the best choice as it can dry out the wound and may not provide adequate protection against infection. D: Transparent film dressing is not suitable for deep partial-thickness burns as it does not provide the necessary antimicrobial properties and may not allow proper wound healing.

Correct Answer: C

Rationale: The correct answer is C: Dry, cracked lips. Dehydration leads to decreased fluid volume in the body, causing dryness and cracking of the lips due to lack of moisture. Moist mucous membranes (choice A) are typically seen in hydrated individuals. Increased skin turgor (choice B) is a sign of dehydration, but dry, cracked lips are more specific. Bounding peripheral pulses (choice D) are associated with conditions like fluid overload or increased blood volume, not dehydration. Dry, cracked lips are a key indicator of dehydration due to the direct impact of fluid depletion on mucous membranes.