When providing care for a comatose patient, how should a nurse evaluate motor responses?

By using the Romberg test

By assessing the patient’s sensitivity to temperature and touch

By observing the patient’s response to painful stimuli

By observing the reaction of pupils to light

Answer and Explanation

The Correct Answer is C

Choice C rationale
When providing care for a comatose patient, a nurse should evaluate motor responses by observing the patient’s response to painful stimuli. This can be done by applying a painful stimulus, such as a trapezius pinch or nailbed pressure, and observing the patient’s motor response. Purposeful or semi-purposeful movements, such as localizing or withdrawing from pain, can provide valuable information about the patient’s level of consciousness and neurological function.
Choice A rationale
The Romberg test is used to evaluate balance and is not typically used to evaluate motor responses in a comatose patient.
Choice B rationale
Assessing the patient’s sensitivity to temperature and touch can provide information about sensory function, but it does not directly evaluate motor responses.
Choice D rationale

Observing the reaction of pupils to light can provide information about cranial nerve function, but it does not directly evaluate motor responses.

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Correct Answer is A

Explanation

Choice A rationale
If a patient is suspected of having meningitis, the provider will likely prescribe antibiotic therapy after reviewing the lab results. Meningitis is often caused by a bacterial infection, and antibiotics are the primary treatment. The specific antibiotic prescribed will depend on the type of bacteria causing the infection.
Choice B rationale
Antiemetics are medications that help prevent and treat nausea and vomiting. They are not typically used as the primary treatment for meningitis.
Choice C rationale

Analgesics are medications that relieve pain. While they may be used to help manage symptoms in a patient with meningitis, they are not used to treat the underlying infection.
Choice D rationale
Antiviral therapy may be used if the meningitis is caused by a viral infection. However, most cases of meningitis are caused by bacteria, and antibiotics are the primary treatment.

A. Follow up by having the client perform the Rinne test B. Reposition the client supine to ensure safety. C. Document successful completion of the assessment. D. Facilitate a referral to a neurologist.

Correct Answer is C

Explanation

Choice A rationale
The Rinne test is a hearing test used to evaluate the difference between sound transmission through air conduction versus bone conduction. It is not typically used following a Romberg test, which evaluates balance.
Choice B rationale
While ensuring the patient’s safety is always important, repositioning the client supine is not the typical response to slight swaying during a Romberg test.
Choice C rationale
Slight swaying during a Romberg test is considered normal. Therefore, documenting successful completion of the assessment would be the appropriate action.
Choice D rationale
A referral to a neurologist is not typically necessary for slight swaying during a Romberg test, as this is considered within normal limits.

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When providing care for a comatose patient, how should a nurse evaluate motor responses?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient suspected of having meningitis. After reviewing the lab results, which medication does the nurse anticipate the provider will prescribe to treat the meningitis?

Correct Answer is A

Explanation

During the performance of a Romberg test, the nurse observes the client sway slightly. What action should the nurse take?

Correct Answer is C

Explanation

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