A nurse is assessing a client who has suffered a traumatic brain injury. When the nurse applies a stimuli to the client, which of the following responses by the client indicates that the client has suffered an extensive cervical spine injury?

Choice A Reason: This is incorrect because nystagmus is not a response to stimuli, but a condition that causes involuntary eye movements. Nystagmus can be caused by various factors, such as inner ear disorders, brain lesions, or drug toxicity, but not necessarily by cervical spine injury.

Choice B Reason: This is incorrect because decorticate positioning is a response to stimuli that indicates damage to the cerebral cortex or the corticospinal tract. Decorticate positioning is characterized by flexion of the arms and extension of the legs. It does not indicate cervical spine injury, which affects the spinal cord below the brainstem.

Choice C Reason: This is incorrect because lack of any response to stimuli can indicate various levels of brain damage or coma, but not specifically cervical spine injury. Lack of any response can also be influenced by other factors, such as sedation, hypothermia, or shock.

Choice D Reason: This is correct because decerebrate positioning is a response to stimuli that indicates damage to the brainstem or the upper cervical spine. Decerebrate positioning is characterized by extension and outward rotation of the arms and legs. It indicates a severe and life-threatening injury that can impair vital functions, such as breathing and blood pressure.

Choice A Reason: This choice is incorrect. Placing the client into a supine position is not an action that the nurse should take, as it can compromise the airway and increase the risk of aspiration. The nurse should position the client on their side with their head tilted slightly forward to allow saliva and secretions to drain out of their mouth.

Choice B Reason: This choice is incorrect. Applying restraints is not an action that the nurse should take, as it can cause injury and increase agitation. The nurse should protect the client from harm by removing any objects or furniture that may cause harm and padding any hard surfaces with blankets or pillows.

Choice C Reason: This choice is incorrect. Inserting a bite stick into the client's mouth is not an action that the nurse should take, as it can cause injury and obstruction. The nurse should never force anything into the client's mouth during a seizure, as it can damage their teeth, gums, tongue, or jaw.

Choice D Reason: This is a correct choice. Loosening restrictive clothing is an action that the nurse should take, as it can improve breathing and circulation. The nurse should unbutton any tight collars, belts, or ties that may constrict the chest or neck.

Choice E Reason: This is a correct choice. Placing a pillow under the client's head is an action that the nurse should take, as it can prevent injury and provide comfort. The nurse should support the client's head with a soft pillow or cushion to prevent hitting it against any hard surfaces.