A client is admitted following a motor vehicle collision.
When assessing the client's level of consciousness, the nurse notes that the client no longer responds to commands.
The nurse initiates a painful stimulus and the client responds by pulling the arms inward with elbows and wrists flexed and extending the legs with the toes pointed downward.
Which action should the nurse implement?
Report the finding to the healthcare provider.
Document the purposeful response to pain.
Initiate seizure precautions immediately.
Administer a prescribed PRN analgesic.
The Correct Answer is A
Choice A rationale: The described posture is decorticate posturing, a sign of severe brain damage. This indicates a deteriorating neurological status and requires immediate reporting to the healthcare provider to prevent further injury.
Choice B rationale: The client's response is a non-purposeful, reflexive motor movement rather than a purposeful attempt to remove the painful stimulus. Documenting it as a purposeful response would be clinically inaccurate and misleading.
Choice C rationale: While neurological injury increases seizure risk, decorticate posturing is a direct sign of midbrain or cortical dysfunction. The immediate priority is addressing the underlying cause of the abnormal posturing and neurological decline.
Choice D rationale: Administering an analgesic could mask further neurological changes and depress the central nervous system. The priority is a full neurological assessment and notifying the physician of the client's severe motor response.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Assessment of tobacco use geared toward adolescents is an important topic, but it may not directly address the immediate concerns related to the increase in suicides in the community. While substance abuse can be a risk factor for mental health issues, focusing on stress self-management techniques may be more relevant in this context as it can help adolescents cope with various stressors and emotions that could contribute to suicidal thoughts.
Choice C rationale:
Showing statistics on suicide rates may be informative but may not be the most engaging and effective approach to teaching adolescents about mental health. Statistics alone may not provide them with practical tools and strategies to manage their mental well-being.
Choice D rationale:
Providing handouts for local substance abuse treatment centers is important if substance abuse is a concern, but it may not address the broader issue of mental health and suicide prevention. The primary focus should be on teaching adolescents how to manage stress and emotions in a healthy way, as this can be a preventive measure for various mental health issues, including suicidal thoughts.
Correct Answer is D
Explanation
The correct answer is D. Notify your healthcare provider if you start having abdominal pain.
Choice A rationale:
Exenatide does not act in the same way as insulin. Insulin directly lowers blood glucose levels by facilitating the uptake of glucose into cells, while exenatide is an incretin mimetic that enhances glucose-dependent insulin secretion and slows gastric emptying.
Choice B rationale:
Exenatide should be injected within 30 minutes before or after a meal, but this is not the most critical information for discharge instructions.
Choice C rationale:
There are precautions about taking exenatide with other medications, especially those that affect kidney function or interact with exenatide.
Choice D rationale:
Notifying the healthcare provider if abdominal pain starts is crucial because exenatide can cause side effects such as pancreatitis, which presents with severe abdominal pain. Early detection and intervention are essential for patient safety.
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