A patient that is Comatose based on the Level of Consciousness (LOC) assessment using the Glasgow Coma scale is in what numeric range of the scale?

3-6

13-15

9-12

Answer and Explanation

The Correct Answer is A

A.   3- This is the lowest possible score on the GCS and reflects no eye opening, no verbal response, and no motor response to stimuli. Score of 4-6: The patient might exhibit some responses, but these responses are still severely impaired. For example, the patient might open their eyes to pain but not respond verbally or move purposefully.
B.   A GCS score in the range of 13 to 15 reflects a higher level of consciousness.
C.   A GCS score of 0 is not a valid score on the scale.
D.   A GCS score in the range of 9 to 12 reflects moderate impairment of consciousness.

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Correct Answer is D

Explanation

A. Perseveration refers to the repetition of a particular response or behavior despite the cessation of the stimulus that prompted it. This often occurs in individuals with neurological disorders, where they keep repeating the same word, phrase, or action.
B. Flight of ideas is a rapid flow of thoughts where the person moves quickly from one topic to another, often with tangential or disconnected ideas. It is commonly observed in conditions such as mania or hypomania.
C. Derailment, also known as loosening of associations, is a thought disorder where a person’s speech goes off-topic and seems disorganized. The connections between ideas are loose or fragmented, making the conversation difficult to follow.
D. Confabulation is a memory disturbance where a person creates false memories or fabricated details to fill in gaps in their memory. The individual does not intentionally deceive but genuinely believes their fabricated information is true.

A. Assess dilatation of pupils with direct light. B. Ask the client to differentiate between sharp and dull sensations on the client's face. C. Palpates temporal and masseter muscles while client clenches teeth. D. Have the client smile, frown, and wrinkle the forehead.

Correct Answer is C

Explanation

A. This test assesses the function of the oculomotor nerve (CN III), not the trigeminal nerve. The oculomotor nerve controls the constriction and dilation of the pupils, as well as some eye movements. Therefore, this choice is not appropriate for assessing the trigeminal nerve.
B. This test assesses the sensory function of the trigeminal nerve (CN V). The trigeminal nerve provides sensation to the face, and testing the ability to differentiate between sharp and dull sensations evaluates

the sensory component of this nerve. However, this test does not assess the motor function of the trigeminal nerve.
C. This test evaluates the motor function of the trigeminal nerve. The trigeminal nerve controls the muscles involved in chewing, including the temporal and masseter muscles. By palpating these muscles while the client clenches their teeth, the nurse assesses the strength and function of these muscles, which are innervated by the trigeminal nerve. This is a direct test of motor function for CN V.
D. This test assesses the function of the facial nerve (CN VII), which controls the muscles of facial expression. It is not relevant for assessing the trigeminal nerve, which is involved in both sensory functions of the face and motor functions related to chewing.

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A patient that is Comatose based on the Level of Consciousness (LOC) assessment using the Glasgow Coma scale is in what numeric range of the scale?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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