Nokea
The nurse provides care for a client who is comatose and needs to collect motor response data. Which nursing action is appropriate?
- A. Using the Romberg test
- B. Observing the reaction of pupils to light
- C. Observing the client's response to painful stimuli
- D. Monitoring the client's sensitivity to temperature, touch, and pain
Correct Answer: C
Rationale: Assessment of motor function includes muscle movement, size, tone, strength, and coordination. The nurse evaluates motor response in the comatose or unconscious client by administering a painful stimulus to determine the client's response. An appropriate response is for the client to reach toward or withdraw from the stimulus. The Romberg test is used to assess equilibrium in a noncomatose client. Observing the reaction of the client's pupils to light is an oculomotor cranial nerve assessment. Monitoring sensitivity to temperature, touch, and pain assesses the sensory function of the client and not motor response.
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The nurse is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly?
- A. Moving the head toward both sides
- B. Lightly tapping the lower portion of the neck to detect sensation
- C. Moving the head and chin toward the chest
- D. Gently pressing the bones on the neck
Correct Answer: C
Rationale: The neck is examined for stiffness or abnormal position. The presence of rigidity is assessed by moving the head and chin toward the chest. The nurse should not maneuver the neck if a head or neck injury is suspected or known. The neck should also not be maneuvered if trauma to any part of the body is evident. Moving the head toward the sides or pressing the bones on the neck will not help assess for neck rigidity correctly. While assessing for neck rigidity, sensation at the neck area is not assessed.
Which neurons transmit impulses from the CNS?
- A. Sensory
- B. Neurilemma
- C. Dendrites
- D. Motor
Correct Answer: D
Rationale: Neurons are either sensory or motor. Sensory neurons transmit impulses to the CNS; motor neurons transmit impulses from the CNS. A membranous sheath called the neurilemma covers the myelin of axons in peripheral nerves. Dendrites are nerve fibers.
The nurse provides care for a client with a deteriorating neurologic status. The nurse collects data at the beginning of the shift that reveals a falling blood pressure (BP) and heart rate (HR), and the client makes no motor response to stimuli. Which documentation of neuromuscular status is most appropriate?
- A. Flaccidity
- B. Abnormal posture
- C. Weak muscular tone
- D. Decorticate posturing
Correct Answer: A
Rationale: The nurse should document flaccidity when the client makes no motor response to stimuli. Clients with impaired cerebral function manifest abnormal posturing, which is documented by the nurse as either decorticate posturing (decorticate rigidity), a position in which the arms are flexed, fists are clenched, and the legs are extended or decerebrate posturing (decerebrate rigidity), when the extremities are stiff and rigid. Muscle tone is documented using a scale of 0 to 5; therefore, weak muscular tone is not the most appropriate documentation.
The nurse scores the client's level of consciousness (LOC) using the Glasgow Coma Scale. Which score should indicate to the nurse that the client needs emergency attention?
- A. A score of 9
- B. A score of 11
- C. A score of 12
- D. A score of 15
Correct Answer: A
Rationale: A score of 9 indicates that the client needs emergency attention. Scores greater than or equal to 11 are considered within normal range.
The nurse is assessing the assigned client's level of consciousness during morning rounds. The nurse speaks the client's name, strokes the client's hand, and moves the client's shoulder. There is a delay, and then the client states, 'What do you want?' Which level of consciousness should the nurse document?
- A. Conscious
- B. Semicomatose
- C. Somnolent
- D. Stuporous
Correct Answer: C
Rationale: Somnolent or lethargy means that the client is drowsy or sleepy at inappropriate times. This is an improvement from the stuporous state, which includes arousing the client only with vigorous and repeated stimulation. A client that is conscious is alert and responds to stimulation immediately. A client is documented as semicomatose when the client only responds to superficial, relatively mild, painful stimuli.