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.

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Choice A rationale:

“Reflection is thinking about what I did and how I can improve.” Rationale: Reflection involves self-assessment and critical thinking about past actions to identify areas for improvement. This statement correctly defines reflection and does not indicate a need for further teaching.

Choice B rationale:

“Analysis is breaking down a complex situation into smaller parts.” Rationale: Analysis is the process of examining complex situations by breaking them down into smaller, manageable components for a more in-depth understanding. This statement accurately describes analysis and does not indicate a need for further teaching.

Choice C rationale:

“Inference is making assumptions based on my experience.” Rationale: Inference involves drawing conclusions or making predictions based on available evidence rather than personal experience. This statement incorrectly defines inference, indicating a need for further teaching.

Choice D rationale:

“Evaluation is checking the reliability and validity of information.” Rationale: Evaluation refers to the process of assessing the credibility, accuracy, and relevance of information or data. This statement accurately defines evaluation and does not indicate a need for further teaching.

A. The client will have no signs of infection in the wound by day 7. B. The client will report pain level of 4/10 or less during dressing changes. C. The client will consume at least 75% of meals and snacks daily. D. The client will reposition self in bed every 2 hours with assistance. E. The client will demonstrate proper wound care technique before discharge.

Correct Answer is ["A","B","E"]

Explanation

Choice A rationale:

The client will have no signs of infection in the wound by day 7. Rationale: This outcome is appropriate because it sets a specific timeframe (day 7) for assessing the absence of infection in the wound. It provides a clear and measurable criterion for evaluating the effectiveness of the wound care plan.

Choice B rationale:

The client will report a pain level of 4/10 or less during dressing changes. Rationale: Pain management is an essential aspect of wound care. Setting a target pain level (4/10 or less) during dressing changes allows for monitoring and adjustment of pain management strategies, making it an appropriate outcome.

Choice C rationale:

The client will consume at least 75% of meals and snacks daily. Rationale: While nutrition is important for wound healing, this outcome is less directly related to the wound itself. Monitoring meal consumption is a valuable goal for overall health but may not be as closely tied to wound improvement as infection control, pain management, or wound care technique.

Choice D rationale:

The client will reposition self in bed every 2 hours with assistance. Rationale: Repositioning every 2 hours is an important preventive measure for pressure ulcer development. However, this choice may not be appropriate for this particular client if they are unable to reposition themselves, even with assistance. This outcome may not be achievable for all clients, and a more individualized goal may be necessary.

Choice E rationale:

The client will demonstrate proper wound care technique before discharge. Rationale: Ensuring that the client can perform proper wound care techniques independently or with minimal assistance is a crucial outcome. This ensures that the client can maintain wound hygiene and prevent complications after discharge.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a group of nursing students about the components of critical thinking. Which of the following statements by a student indicates a need for further teaching?

Correct Answer is C

Explanation

A nurse is updating the plan of care for a client who has a pressure ulcer on the sacrum. Which of the following outcomes are appropriate for this client? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Which information should the practical nurse (PN) collect during the admission assessment of a terminally ill client to an acute care facility?

A client with diabetic peripheral neuropathy has been taking pregabalin for 4 days. Which finding indicates to the nurse that the medication is effective?

The nurse is developing an educational program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure that the educational materials include which characteristics? (Select all that apply.).

A 5-year-old child with a history of a waddling gait and frequent falls is brought into the hospital for diagnostic testing. When explaining the diagnostic testing to the parents, the nurse should provide information based on which understanding of the underlying disease pathology?

Patient Data. Exhibits What are three goals of therapy for this client? Select three that apply.

A client who has been prescribed propranolol for the treatment of arrhythmias reports experiencing shortness of breath and difficulty breathing while lying down at night. Which of the following should the nurse instruct the client to do?