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 A
The correct answer is **a. Report the finding to the healthcare provider.**
Choice A rationale:
The nurse should report the finding of the client's response to a painful stimulus to the healthcare provider. This response, known as a decorticate posturing, is an abnormal motor response that indicates a severe brain injury or dysfunction. It is a sign of impaired consciousness and requires immediate medical attention and intervention.
Choice B rationale:
While documenting the client's response to pain is important, the primary action the nurse should take is to report the finding to the healthcare provider. Decorticate posturing is a neurological emergency that requires prompt medical evaluation and treatment.
Choice C rationale:
Initiating seizure precautions is not the appropriate action in this case. Decorticate posturing is not a seizure, but rather an abnormal motor response indicating a severe brain injury or dysfunction. Seizure precautions would not be the appropriate intervention.
Choice D rationale:
Administering a prescribed PRN analgesic is not the appropriate action in this case. Decorticate posturing is a neurological emergency that requires immediate medical attention, not just pain management. Administering an analgesic would not address the underlying neurological issue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Choice B rationale:
Choice C rationale:
Severe motor dysfunction determines the extent of successful habilitation is not entirely accurate. While the severity of motor dysfunction does play a role in the challenges a child with CP may face, it does not solely determine the extent of successful habilitation. Many factors, including early intervention, therapy, and individualized care, can influence a child's progress and potential for improvement.
Choice D rationale:
Continued development of the brain lesion determines the child's outcome is not an accurate statement. CP is primarily caused by non-pro
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale: Depression assessment is important in bariatric care, but postoperative priorities focus on physiologic risks—venous thromboembolism, pulmonary complications, bleeding, and leaks—heightened by obesity, diabetes, hypertension, and immobility; psychosocial screening is longitudinal.
Choice B rationale: Urinary incontinence is not a typical complication of gastroplasty. Immediate risks include venous thromboembolism, pulmonary issues, hemorrhage, anastomotic leak, and infection; prioritizing VTE prophylaxis and respiratory support offers morbidity reduction.
Choice C rationale: Early post-gastroplasty nutrition requires staged progression: clear liquids to pureed, tiny portions, high-protein focus, vitamin-mineral supplementation. Offering meal variety risks overeating, nausea, vomiting, dumping syndrome, and staple-line stress or disruption.
Choice D rationale: Sequential compression devices augment venous return, reduce stasis, and lower deep vein thrombosis and pulmonary embolism risk in obese, diabetic, hypertensive surgical patients with limited mobility; evidence-based venous thromboembolism prophylaxis.
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