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

The correct answer is choice B.

Choice A rationale: Metabolic alkalosis is caused by a loss of acid or a gain of base. It is not typically associated with anxiety or hyperventilation.

Choice B rationale: Respiratory alkalosis is caused by hyperventilation, which leads to a decrease in carbon dioxide levels in the blood. This can occur in response to anxiety, pain, or other stressors.

Choice C rationale: Metabolic acidosis is caused by a buildup of acid in the blood or a loss of bicarbonate. It is not typically associated with anxiety or hyperventilation.

Choice D rationale: Respiratory acidosis is caused by hypoventilation, which leads to an increase in carbon dioxide levels in the blood. It is not typically associated with anxiety or hyperventilation.

A. Protamine sulfate should be given slowly intravenously within 30 minutes of heparin administration. B. Protamine sulfate should be given rapidly intramuscularly within 60 minutes of heparin administration. C. Protamine sulfate should be given slowly intravenously within 60 minutes of heparin administration. D. Protamine sulfate should be given rapidly intramuscularly within 30 minutes of heparin administration.

Correct Answer is A

Explanation

Choice A rationale:

Protamine sulfate is an antidote for heparin overdose and should be administered slowly intravenously to avoid rapid hemodynamic changes and potential adverse reactions.Administering it within 30 minutes ensures timely reversal of heparin’s anticoagulant effects.

Choice B rationale:

Administering protamine sulfate rapidly intramuscularly is incorrect because intramuscular administration is not recommended due to the risk of hematoma formation and slower absorption compared to intravenous administration.

Choice C rationale:

While slow intravenous administration is correct, the timing of 60 minutes is less effective compared to 30 minutes for reversing heparin’s effects promptly.

Choice D rationale:

Rapid intramuscular administration is incorrect for the same reasons as Choice B.Rapid administration can cause adverse reactions, and intramuscular administration is not the preferred route.

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Naxlex Comprehensive Predictor Exams

An adolescent who is brought to the emergency department (ED) with a fever and persistent lower right quadrant abdominal pain is anxious, fearful, and hyperventilating. The nurse anticipates the client developing which acid-base imbalance?

Correct Answer is B

Explanation

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

Correct Answer is A

Explanation

After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to an unlicensed assistive personnel (UAP)?

The nurse is preparing a community outreach program on primary disease prevention. Which topic should the nurse plan to include in this event?

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?

An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasm when taking the blood pressure using the same arm. After confirming the presence of the spasms, which action should the nurse take?

A male preoperative client who has already signed the informed consent for a surgical procedure confides in the practical nurse (PN) that he is really frightened and unsure about undergoing the surgery. Which priority action should the PN take?

The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery. Which menu item(s) should the nurse request for this client? (Select all that apply).

The nurse is assessing an adolescent female diagnosed with anorexia nervosa who is admitted to the unit with severe malnutrition and electrolyte imbalance. Which pathological process results from the adolescent's consistent maladaptive behavior?