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 ["A","B","C","E"]
Explanation
Choice A rationale:
Taking out dentures and placing them in a labeled cup (Choice A) is a necessary step to ensure the comfort and dignity of the deceased. It helps maintain the appearance and respect for the deceased person.
Choice B rationale:
Gently closing the eyes (Choice B) is a common practice to provide a more peaceful and natural appearance to the deceased. It also prevents the eyes from remaining partially open, which can be distressing for family members.
Choice C rationale:
Placing a small pillow under the head (Choice C) is done to maintain the natural alignment of the head and neck. This helps create a more lifelike appearance and enhances the comfort of the deceased.
Choice E rationale:
Removing resuscitation equipment from the room (Choice E) is essential for maintaining the dignity of the deceased and creating a more peaceful environment for the family. It also helps prevent any distressing reminders of the resuscitation attempt.
Choice D rationale:
Apply a body shroud (Choice D) is not a common practice in preparing the body for viewing by the family. The use of a body shroud may vary based on cultural or religious preferences, but it is not a standard procedure in many healthcare settings.
Correct Answer is ["1"]
Explanation
This is the correct answer because the concentration of cefazolin after reconstitution is 1 gram/2.5 mL, which is equivalent to 400 mg/1 mL. Therefore, to administer 400 mg of cefazolin, the PN should draw up 1 mL of the reconstituted solution. This can be calculated using the formula:
Desired dose / Available dose = Volume to administer
400 mg / 1000 mg = x mL / 2.5 mL
x = (400 x 2.5) / 1000
x = 1 mL
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