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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Speaking slowly and clearly using yes/no questions one at a time can help facilitate communication with a client diagnosed with aphasia.
Choice B rationale
Asking a family member if they know what the client wants may not always be effective, as the client may have difficulty expressing their needs even to family members.
Choice C rationale
Repeating the same question multiple times may not be effective and could potentially frustrate the client.
Choice D rationale
Putting a cell phone in their right hand to text their questions assumes that the client has the ability to text, which may not be the case for all clients diagnosed with aphasia.
Correct Answer is A
Explanation
Choice A rationale
The best way to determine if a patient can safely and effectively self-administer medications is to ask the patient to demonstrate the instillation of the medications. This allows the nurse to directly observe the patient’s technique, identify any errors, and provide immediate feedback and instruction. It also gives the patient an opportunity to ask questions and clarify any misunderstandings. This method is often referred to as the “show-back” or “teach-back” method and is widely used in patient education to confirm understanding and competency.
Choice B rationale
While assessing the patient for any previous inability to self-manage medications can provide useful information, it does not directly assess the patient’s ability to self-administer the new eye medications. Previous difficulties may be due to factors that do not apply to the current situation, such as complex medication regimens, cognitive impairment, or lack of resources.
Choice C rationale
Although the patient accurately describing the directions for administering the medications indicates that the patient understands the instructions, it does not necessarily mean that the patient can perform the task correctly. Physical limitations, dexterity issues, or misunderstanding of the instructions can still result in incorrect administration.
Choice D rationale
Assessing the patient’s functional status can provide valuable information about the patient’s overall ability to perform activities of daily living, including medication management.
However, it does not specifically assess the patient’s ability to self-administer eye medications.
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