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.

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Correct Answer is B

Explanation

Choice A rationale:

The statement, "This medication will help regulate my mood and anxiety," is an accurate description of how antidepressants work. Antidepressants can help improve mood and reduce anxiety symptoms over time.

Choice B rationale:

This is the correct answer. Expecting immediate results from antidepressant medication is a misunderstanding. Antidepressants typically take several weeks to show their full therapeutic effects. Clients need to be informed about the delayed onset of action.

Choice C rationale:

The statement, "I may experience side effects such as nausea and drowsiness," is accurate. Antidepressants can indeed cause side effects, including gastrointestinal symptoms like nausea and drowsiness. This information is essential for the client to be aware of.

Choice D rationale:

This statement is correct. It is crucial to take antidepressant medication consistently as prescribed for the best therapeutic outcomes. Stopping or missing doses without consulting a healthcare provider can lead to treatment ineffectiveness.

A. Check the client’s temperature B. Assess the client’s level of consciousness. C. Ask the client about any history of allergies. D. Obtain a blood sample for culture and sensitivity.

Correct Answer is D

Explanation

Choice A rationale:

Checking the client's temperature is important for assessing the client's condition, but it is not a priority before administering penicillin G IV for meningitis.

Choice B rationale:

Assessing the client's level of consciousness is essential for monitoring neurological status, but it is not the highest priority action before administering penicillin G IV for meningitis.

Choice C rationale:

Asking the client about any history of allergies is important for assessing potential allergic reactions to medications. However, the most critical action before administering penicillin G IV for meningitis is to obtain a blood sample for culture and sensitivity. This action helps identify the causative organism and guides appropriate antibiotic therapy, as meningitis can be life-threatening and requires prompt treatment.

Choice D rationale:

Obtaining a blood sample for culture and sensitivity is the highest priority action before administering penicillin G IV for meningitis. Identifying the specific pathogen responsible for the infection is crucial for selecting the most effective antibiotic therapy and preventing complications.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing education to a client prescribed an antidepressant for their phobia. Which statement by the client indicates a need for further teaching?

Correct Answer is B

Explanation

A nurse is caring for a client who has meningitis caused by Streptococcus pneumoniae. The provider orders penicillin G IV for this client. Before administering the medication, which of the following actions should the nurse take?

Correct Answer is D

Explanation

An unresponsive male victim of a diving accident is brought to the emergency department where it is determined that immediate surgery is required to save his life. The client is accompanied by a close friend, but no family members are available. Which action should the nurse take first?

A client is admitted with an exacerbation of heart failure secondary to chronic obstructive pulmonary disease (COPD). Which observation(s) by the nurse require immediate intervention to reduce the likelihood of harm to this client? (Select all that apply.).

What are some important nursing considerations for this medication? *.

A nurse is administering tetracycline to a client who has acne vulgaris. The client tells the nurse that he usually takes calcium supplements with his meals. How should the nurse respond?

At the first dressing change, the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best?

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A client has been diagnosed with depression and has a history of suicide attempts. What intervention is essential for the nurse to implement?

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