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?
Nystagmus
Decorticate positioning
Lack of any response
Decerebrate positioning
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because right-sided homonymous hemianopsia means that the client has lost vision in the right half of both eyes, so placing food trays on the left side of the client will help them see and access their food better.
Choice B reason: This is incorrect because placing food trays on the right side of the client will make it harder for them to see and reach their food, as they have no vision on that side.
Choice C reason: This is incorrect because performing a focused visual exam is not an appropriate action for the nurse to take during meal time. The nurse should assess the client's vision before or after meals, but not interfere with their eating.
Choice D reason: This is incorrect because having the assistive personnel feed all meals to the client will decrease their independence and dignity, as well as their ability to practice using their unaffected side. The nurse should encourage and assist the client to feed themselves as much as possible, and only provide assistance when needed.
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because a referral to a sleep study program is not the most appropriate plan of care for a blind client who has difficulty with sleep. A sleep study program is used to diagnose and treat sleep disorders such as sleep apnea, narcolepsy, or restless legs syndrome.
Choice B Reason: This is incorrect because assisting the client to see if a night shift job is available is not a helpful plan of care for a blind client who has difficulty with sleep. A night shift job can disrupt the circadian rhythm and worsen the sleep quality and quantity of the client.
Choice C Reason: This is incorrect because institution of opioids and sedatives is not a safe plan of care for a blind client who has difficulty with sleep. Opioids and sedatives can cause addiction, dependence, tolerance, and withdrawal symptoms. They can also impair the respiratory and cognitive functions of the client.
Choice D Reason: This is the correct choice because education about non-24 disorder is an essential plan of care for a blind client who has difficulty with sleep. Non-24 disorder is a condition where the internal clock of the body does not synchronize with the 24-hour day-night cycle. It can cause irregular sleep patterns, daytime fatigue, and mood disturbances. It is more common in blind people who lack light perception. The nurse should educate the client about the causes, symptoms, and treatments of non-24 disorder.
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