Page 2013 - Saunders Comprehensive Review For NCLEX-RN

4. Flaccid posturing: Client displays no motor response
in any extremity.

I. Assessment of reflexes (Box 58-3)

J. Assessment of meningeal irritation (Box 58-4)

K. Assessment of the autonomic system
1. Sympathetic functions, adrenergic responses
a. Increased pulse and blood pressure
b. Dilated pupils
c. Decreased peristalsis
d. Increased perspiration
2. Parasympathetic function, cholinergic responses
a. Decreased pulse and blood pressure
b. Constricted pupils
c. Increased salivation
d. Increased peristalsis
e. Dilated blood vessels
f. Bladder contraction
L. Assessment of sensory function: Touch, pressure, pain

M. Glasgow Coma Scale (Box 58-5)

1. The scale is a method of assessing a client’s
neurological condition.
2. The scoring system is based on a scale of 3 to 15
points.
3. A score lower than 8 indicates that coma is present.
IV. The Unconscious Client
A. Description
1. The unconscious client is in a state of depressed
cerebral functioning with unresponsiveness to
stimulation of sensory and motor function.
2. Some causes include head trauma, cerebral toxins,
shock, hemorrhage, tumor, and infection.
B. Assessment
1. Unarousable
2. Primitive or no response to painful stimuli
3. Altered respirations
4. Decreased cranial nerve and reflex activity
C. Interventions (Box 58-6)

V. Increased Intracranial Pressure (ICP)
A. Description
1. Increased ICP may be caused by trauma, hemorrhage,
growths or tumors, hydrocephalus, edema, or
inflammation.
2. Increased ICP can impede circulation to the brain,

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