Critical Care Registered Nurse (CCRN) Practice Exam

What is the first step in the arousal assessment process?

1. Tactile stimulus

2. Auditory stimulus

3. Painful stimulus

4. Visual stimulus

The correct answer is: Auditory stimulus

The initial step in the arousal assessment process typically involves applying an auditory stimulus. This approach begins the evaluation of a patient's responsiveness in a non-invasive and less distressing manner. By using sounds, such as calling the patient's name or using a bell or similar object, the caregiver can gauge whether the patient can respond or demonstrate awareness without causing discomfort. This method is beneficial as it allows for a gentle way to assess responsiveness, as the auditory stimulus often stimulates patients who may be in a light state of sedation or altered levels of consciousness. If the patient does not respond to the auditory cue, clinicians will generally escalate the stimulus intensity progressively, which may lead them to utilize tactile or painful stimuli next. When evaluating the process of arousal assessment, using auditory methods is a standard protocol in clinical practice because it respects the patient's dignity and minimizes unnecessary pain at the early stage of assessment.