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
Antiviral therapy is typically used to treat viral infections. However, meningitis is most commonly caused by bacteria. Therefore, antiviral therapy would not be the most effective treatment in this case.
Choice B rationale
Antibiotic therapy is the standard treatment for bacterial meningitis. The specific antibiotic or combination of antibiotics used depends on the type of bacteria causing the infection.
Therefore, after reviewing lab results that suggest meningitis, the nurse would anticipate the provider to prescribe antibiotic therapy.
Choice C rationale
Antiemetics are medications that help prevent and treat nausea and vomiting, which can be symptoms of meningitis, but they do not treat the underlying cause of meningitis.
Choice D rationale
Analgesics are used to relieve pain. While they might be used to manage the headache often associated with meningitis, they would not treat the infection itself.
Correct Answer is ["0.9 "]
Explanation
Step 1: We are instructed to administer tobramycin 35mg IM every 8 hours. The available supply is 40mg in a 1 mL vial.
Step 2: We need to find out how many mL’s should the nurse administer. Step 3: We can set up a proportion to solve this.
Step 4: If 40mg is equivalent to 1mL, then 35mg is equivalent to x mL. Step 5: Solving for x gives us x = (35mg ÷ 40mg) × 1mL.
Step 6: Calculating the above expression gives us x = 0.875 mL.
Step 7: Rounding our answer to the nearest tenth, we get 0.9 mL. So, the nurse should administer 0.9 mL.
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