A patient that is Comatose based on the Level of Consciousness (LOC) assessment using the Glasgow Coma scale is in what numeric range of the scale?

3-6

13-15

9-12

Answer and Explanation

The Correct Answer is A

A.   3- This is the lowest possible score on the GCS and reflects no eye opening, no verbal response, and no motor response to stimuli. Score of 4-6: The patient might exhibit some responses, but these responses are still severely impaired. For example, the patient might open their eyes to pain but not respond verbally or move purposefully.
B.   A GCS score in the range of 13 to 15 reflects a higher level of consciousness.
C.   A GCS score of 0 is not a valid score on the scale.
D.   A GCS score in the range of 9 to 12 reflects moderate impairment of consciousness.

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Correct Answer is C

Explanation

A. The Babinski reflex is a test used to assess the integrity of the corticospinal tract and is particularly useful in evaluating neurological function in infants and adults with neurological conditions. However, it is not specifically related to testing for meningeal irritation.
B. Positioning the client prone (lying on their stomach) is not typically used when testing for meningeal irritation. The tests for meningeal irritation, such as the Brudzinski sign and Kernig sign, are performed with the client in a supine (lying on their back) position to accurately assess reactions to neck flexion and leg movements.
C. Before performing tests for meningeal irritation, such as neck flexion, it is important to ensure that the client does not have an injury to the cervical spine. If there is a possibility of cervical spine injury, performing neck flexion could exacerbate the injury. Ensuring that there is no cervical spine injury helps to avoid causing harm and ensures a safe examination.
D. While fever and chills can be associated with infections that may cause meningeal irritation (such as meningitis), checking for these symptoms is not the first step in assessing meningeal irritation itself.

A. Assess dilatation of pupils with direct light. B. Ask the client to differentiate between sharp and dull sensations on the client's face. C. Palpates temporal and masseter muscles while client clenches teeth. D. Have the client smile, frown, and wrinkle the forehead.

Correct Answer is C

Explanation

A. This test assesses the function of the oculomotor nerve (CN III), not the trigeminal nerve. The oculomotor nerve controls the constriction and dilation of the pupils, as well as some eye movements. Therefore, this choice is not appropriate for assessing the trigeminal nerve.
B. This test assesses the sensory function of the trigeminal nerve (CN V). The trigeminal nerve provides sensation to the face, and testing the ability to differentiate between sharp and dull sensations evaluates

the sensory component of this nerve. However, this test does not assess the motor function of the trigeminal nerve.
C. This test evaluates the motor function of the trigeminal nerve. The trigeminal nerve controls the muscles involved in chewing, including the temporal and masseter muscles. By palpating these muscles while the client clenches their teeth, the nurse assesses the strength and function of these muscles, which are innervated by the trigeminal nerve. This is a direct test of motor function for CN V.
D. This test assesses the function of the facial nerve (CN VII), which controls the muscles of facial expression. It is not relevant for assessing the trigeminal nerve, which is involved in both sensory functions of the face and motor functions related to chewing.

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A patient that is Comatose based on the Level of Consciousness (LOC) assessment using the Glasgow Coma scale is in what numeric range of the scale?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When preparing to test a client for meningeal irritation, what would the nurse do first?

Correct Answer is C

Explanation

Which of the following tests would be most appropriate for the nurse to use when assessing motor function of the trigeminal nerve?

Correct Answer is C

Explanation

Which are the 3 areas included in the Glasgow Coma Scale to assess levels of consciousness? Select all that Apply.

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