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 B
Explanation
Choice A rationale
Instilling mineral oil into the canal and immediately irrigating to remove the impacted wax is not typically recommended. This approach may not allow enough time for the mineral oil to soften the cerumen, making it more difficult to remove and potentially causing discomfort or injury.
Choice B rationale
Instilling a small amount of mineral oil into the canal, then having the patient return in 30 minutes for wax removal is a common and effective method for managing cerumen impaction. The mineral oil helps to soften the cerumen, making it easier to remove through irrigation.
Choice C rationale
Irrigating the ear with cold water is not typically recommended. Cold water can cause discomfort and potentially lead to vertigo.
Choice D rationale
Irrigating the ear with warm water and a high amount of otic pressure is not typically recommended. High pressure can potentially damage the ear canal or tympanic membrane.
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.
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