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 B
Choice A rationale:
Reporting the finding to the healthcare provider is important when the client no longer responds to commands and exhibits a specific response to pain. However, it should not be the first action. The nurse's initial response should be to assess and document the client's neurological status and response to pain to provide accurate information to the healthcare provider.
Choice B rationale:
Documenting the purposeful response to pain is the correct initial action in this scenario. The client's response, which involves pulling the arms inward with elbows and wrists flexed and extending the legs with the toes pointed downward, is known as decerebrate posturing. It is a specific neurological response to painful stimuli and may indicate a brain injury. Documenting this response is crucial for the client's medical record and helps the healthcare provider assess the severity of the neurological injury.
Choice C rationale:
Initiating seizure precautions immediately is not the first action to take in this scenario. While the client's response to pain may resemble posturing seen in seizures, it is more indicative of a neurological injury or dysfunction. Further assessment and evaluation are needed before implementing seizure precautions.
Choice D rationale:
Administering a prescribed PRN analgesic is not the first action to take when the client exhibits decerebrate posturing in response to pain. This response indicates a neurological issue or injury that requires assessment and evaluation. Administering pain medication without a clear understanding of the underlying cause may not be appropriate and could potentially mask important neurological signs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale: Moving Client D into an isolation room 24 hours before surgery is not necessary. The client’s white blood cell (WBC) count is 14,000 mm (14 x 10^9/L), which is higher than the normal range of 5000 to 10,000/mm² (5 to 10 x 10^9/L). This indicates that the client may have an infection. However, it is not standard practice to isolate clients scheduled for surgery based solely on an elevated WBC count. Other factors, such as the presence of specific infectious diseases, would dictate the need for isolation.
Choice B rationale: Asking the dietitian to add a banana to Client C’s breakfast tray is not necessary. The client’s potassium level is 3.8 mEq/L (3.8 mmol/L), which is within the normal range of 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Therefore, there is no need to increase the client’s potassium intake.
Choice C rationale: Increasing Client A’s oxygen to 4 liters a minute per cannula is not necessary. The client has emphysema and their oxygen saturation is 94%, which is within the normal range. Increasing the oxygen flow rate could lead to oxygen toxicity or suppress the client’s respiratory drive, leading to respiratory depression or failure.
Choice D rationale: Verifying that Client B has two units of packed cells available is the correct intervention. The client’s postoperative hemoglobin level is 8.2 mg/dL (82 g/L), which is lower than the normal range of 14 to 18 g/dL (140 to 180 g/L). This indicates that the client is anemic and may require a blood transfusion. Therefore, it is important to ensure that packed cells are available if needed.
Correct Answer is B
Explanation
Choice A rationale:
Increasing the supplemental oxygen to 15 L/min via nasal cannula may seem like a logical step given the client’s low oxygen saturation. However, it’s important to note that oxygen therapy should be titrated carefully. Too much oxygen can lead to oxygen toxicity, which can cause cellular damage and worsen the client’s condition. Therefore, this is not the priority action.
Choice B rationale:
Notifying the health care provider of the client’s condition is the priority action. The client’s oxygen saturation is 88% on room air, which is below the normal range of 95% to 100%. This indicates that the client is not getting enough oxygen, which can lead to hypoxia and other serious complications. The health care provider needs to be informed immediately so that appropriate interventions can be initiated.
Choice C rationale:
Administering ibuprofen as ordered for fever is important, but it’s not the priority in this situation. While fever can indicate an infection, which could be contributing to the client’s low oxygen saturation, addressing the immediate issue of hypoxia is more critical.
Choice D rationale:
Obtaining a sputum culture from the client could provide valuable information about the type of bacteria causing the pneumonia and guide antibiotic therapy. However, this is not an immediate priority compared to addressing the client’s low oxygen saturation. In summary, while all these actions are important in caring for a client with pneumonia, the nurse must prioritize interventions based on their urgency and potential impact on the client’s health status. In this case, notifying the health care provider of the client’s condition is the most critical action.
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