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
The patient lying in bed with their head elevated to 35 degrees while eating could pose a risk for aspiration, especially for a patient with Huntington’s disease. Huntington’s disease is a neurodegenerative disorder that can cause difficulties with swallowing and motor control.
Therefore, it is recommended that the patient be as upright as possible, ideally in a seated position, during meals to reduce the risk of aspiration.
Choice B rationale
Providing thickened liquids is a common intervention for patients with Huntington’s disease who have difficulty swallowing. Thickened liquids are easier to control and swallow, reducing the risk of aspiration.
Choice C rationale
Not rushing the patient in eating each bite is a recommended practice. Patients with Huntington’s disease often have difficulty with motor control, including swallowing. Allowing the patient to take their time can help prevent choking and aspiration.
Choice D rationale
Ensuring that the patient’s food is minced is another recommended practice for patients with Huntington’s disease. Minced food is easier to chew and swallow, which can help prevent choking and aspiration.
Correct Answer is ["4 "]
Explanation
The nurse is preparing to administer 40 mg of furosemide intravenously. The available furosemide is 10 mg/1 mL.
Step 1 is: Calculate the dose in mL using the formula: (Desired dose ÷ Available dose) × Volume.
Step 2 is: Substitute the given values into the formula: (40 mg ÷ 10 mg) × 1 mL = 4 mL. The nurse should administer 4 mL per dose.
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