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 C
Explanation
The correct answer is: C. Bronchospasm.
Metoprolol is a selective beta-1 blocker, primarily affecting the heart, but it can still have some impact on beta-2 receptors in the lungs. In clients with respiratory conditions like asthma or COPD, beta-blockers can trigger bronchospasm, leading to breathing difficulties.
Here's why the other options are less likely to be adverse effects of metoprolol:
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A. Tachycardia: Metoprolol actually lowers heart rate, so tachycardia is not a typical adverse effect. Instead, bradycardia (slow heart rate) is more common.
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B. Hyperglycemia: Beta-blockers can sometimes mask symptoms of hypoglycemia, but they don’t directly cause high blood sugar.
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D. Hyperkalemia: Metoprolol doesn’t significantly affect potassium levels, so hyperkalemia is not a common concern.
Since metoprolol is frequently used in hypertension management, nurses must monitor clients for bradycardia, hypotension, and signs of bronchospasm, especially in individuals with respiratory disorders.
Correct Answer is C
Explanation
When a preoperative client expresses fear and uncertainty about undergoing surgery, the priority action for the practical nurse (PN) is to notify the charge nurse of the client's concerns. This is important because the charge nurse can coordinate appropriate interventions and support for the client, ensuring their emotional well-being and addressing their fears.
Let's evaluate the other options:
a) Encourage the client to continue with the scheduled surgery.
While it is important to provide support and reassurance to the client, simply encouraging them to continue with the scheduled surgery may not adequately address their specific concerns and fears. The charge nurse and the healthcare team should be involved to provide the necessary support and information to help alleviate the client's anxiety.
b) Document that the client has expressed concerns about the surgery.
Documenting the client's concerns is important for accurate record-keeping and continuity of care. However, it should not be the only action taken. Notifying the charge nurse is crucial to ensure appropriate follow-up and support for the client.
d) Remind the client that the consent has already been obtained.
Reminding the client that they have already signed the informed consent may not effectively address their fears and concerns. Reassurance and support should be provided, and involving the charge nurse and healthcare team is essential to address the client's emotional well-being.
In summary, when a preoperative client confides in the practical nurse (PN) about being frightened and unsure about undergoing surgery, the priority action is to notify the charge nurse of the client's concerns. This allows for appropriate interventions, support, and coordination of care to address the client's fears, ensure their emotional well-being, and provide necessary information about the surgical procedure.
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