The nurse is caring for a comatose client. The nurse knows she should assess the client's motor response. Which method may the nurse use to assess the motor response?
A) Observing the reaction of pupils to light
B) Observing the client's response to painful stimulus
C) Using the Romberg test
D) Assessing the client's sensitivity to temperature, touch, and pain
B
Feedback:
The nurse evaluates motor response in a comatose or unconscious client by administering a painful stimulus. This action helps determine if the client makes an appropriate response by reaching toward or withdrawing from the stimulus. The Romberg test is used to assess equilibrium in a noncomatose client. Pupils are examined for their reaction to light to assess sensitivity in the third cranial (oculomotor) nerve. Sensitivity to temperature, touch, and pain is a test to assess the sensory function of the client and not motor response.
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