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

Facial droop is a classic symptom of stroke. It occurs when there’s weakness or paralysis on one side of the face, which is caused by a disruption in the nerve signals due to a stroke. This can be easily observed in the person’s smile, as it will appear uneven.
Choice B rationale
While dysrhythmias can be associated with stroke, they are not the most indicative symptom. Dysrhythmias are more commonly associated with heart conditions.
Choice C rationale
Periorbital edema, or swelling around the eyes, is not typically a symptom of stroke. It can be caused by various conditions such as allergies, infections, or kidney problems.
Choice D rationale
Projectile vomiting is not typically a symptom of stroke. It can be caused by various conditions such as gastrointestinal issues, brain tumors, or increased intracranial pressure.

A. Ampicillin B. Cyclosporine C. Medication C D. Medication D

Correct Answer is A

Explanation

Choice A rationale
Herpes simplex virus encephalitis is a severe condition that requires immediate treatment. The most common medication used for this condition is acyclovir, which is administered intravenously. Acyclovir works by inhibiting the replication of the virus, thereby reducing the severity and duration of the infection.
Choice B rationale
Cyclosporine is an immunosuppressive medication that is often used to prevent organ rejection after transplantation. It is not typically used in the treatment of viral infections such as herpes simplex virus encephalitis.
Choice C rationale
Without specific information about “Medication C”, it’s difficult to provide a rationale.
However, it’s important to note that the treatment of herpes simplex virus encephalitis typically involves antiviral medications, with acyclovir being the most commonly used.
Choice D rationale
Similar to Choice C, without specific information about “Medication D”, providing a rationale is challenging. As mentioned, the standard treatment for herpes simplex virus encephalitis is acyclovir.

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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

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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