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 D

Explanation

Choice A rationale:
Respiratory acidosis is characterized by a low pH (less than 7.35), a high PaCO2 (greater than 45 mm Hg), and a normal or high HCO3 (22-26 mEq/L). It occurs when there is a buildup of carbon dioxide in the blood due to impaired ventilation.
The patient's ABGs do not align with respiratory acidosis because the pH is elevated (7.6), and the PaCO2 is within the normal range (40 mm Hg).
Choice B rationale:
Respiratory alkalosis is characterized by a high pH (greater than 7.45), a low PaCO2 (less than 35 mm Hg), and a normal or low HCO3 (22-26 mEq/L). It occurs when there is excessive loss of carbon dioxide through hyperventilation.
The patient's ABGs do not align with respiratory alkalosis because the HCO3 is elevated (32 mEq/L), which is not typical for this condition.
Choice C rationale:
Metabolic acidosis is characterized by a low pH (less than 7.35), a normal or low PaCO2 (less than 40 mm Hg), and a low HCO3 (less than 22 mEq/L). It occurs when there is an excess of acid in the body or a loss of bicarbonate.
The patient's ABGs do not align with metabolic acidosis because the pH is elevated (7.6), and the HCO3 is elevated (32 mEq/L).
Choice D rationale:

Metabolic alkalosis is characterized by a high pH (greater than 7.45), a normal or high PaCO2 (40-45 mm Hg), and an elevated HCO3 (greater than 26 mEq/L). It occurs when there is an excess of bicarbonate in the body or a loss of acid.
The patient's ABGs align with metabolic alkalosis because of the high pH (7.6), normal PaCO2 (40 mm Hg), and elevated HCO3 (32 mEq/L).

A. Venous thromboembolism B. Hemorrhage C. Contractures D. Pressure ulcers E. Pneumonia

Correct Answer is ["A","C","D","E"]

Explanation

Choice A rationale

Venous thromboembolism (VTE) is a serious complication that can occur in comatose patients. Immobility is a major risk factor for VTE, and comatose patients are often immobile. Therefore, nurses should be vigilant for signs of VTE, such as swelling, pain, or redness in the extremities.
Choice B rationale
Hemorrhage is not typically a direct complication of coma. However, the underlying cause of the coma, such as a traumatic brain injury, could potentially lead to hemorrhage.
Choice C rationale
Contractures, or the shortening and hardening of muscles, tendons, or other tissue, can occur in comatose patients due to prolonged immobility. Regular movement and physiotherapy can help prevent this complication.
Choice D rationale
Pressure ulcers, also known as bedsores, are a common complication in comatose patients. They occur when there is prolonged pressure on the skin, usually over bony areas. Regular turning and good skin care can help prevent pressure ulcers.
Choice E rationale
Pneumonia is a common complication in comatose patients, often resulting from aspiration (inhaling food, stomach acid, or saliva into the lungs)2. Nurses should be vigilant for signs of pneumonia, such as fever, cough, and difficulty breathing.

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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

A nurse is analyzing the arterial blood gas (ABG) results of a patient. The patient’s ABGs are: pH:7.6, PaCO2:40 mm Hg, HCO3:32 mEq/L. Which of the following acid-base conditions should the nurse identify the patient is experiencing?

Correct Answer is D

Explanation

The nurse is providing care for a comatose patient and regularly assessing for potential complications. What complications should the nurse be looking for?

Correct Answer is ["A","C","D","E"]

Explanation

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