The nurse has just received a report on a group of clients on the neurosurgical unit. Which client is the nurse’s first priority?
Client who displays plantar flexion when the bottom of the foot is stroked.
Client who consistently demonstrates decortication when stimulated.
Client whose Glasgow Coma Scale (GCS) has changed from 15 to 12.
Client whose deep tendon reflexes have become hyperactive.
The Correct Answer is C
Choice A Reason:
The client who displays plantar flexion when the bottom of the foot is stroked is exhibiting a normal reflex response known as the plantar reflex. This response indicates that the corticospinal tract is functioning properly. In adults, the normal response is plantar flexion of the toes, which means the toes curl downward. This is not an immediate cause for concern and does not indicate a life-threatening condition.
Choice B Reason:
The client who consistently demonstrates decortication when stimulated is showing signs of severe brain injury. Decorticate posturing is characterized by the arms being flexed at the elbows and held tightly to the chest, with the legs extended and feet turned inward. This type of posturing indicates damage to the cerebral hemispheres, thalamus, or midbrain. While this is a serious condition, it is not necessarily the most immediate priority compared to a sudden change in the Glasgow Coma Scale.
Choice C Reason:
The client whose Glasgow Coma Scale (GCS) has changed from 15 to 12 is the nurse’s first priority. The GCS is a critical tool used to assess a patient’s level of consciousness, with scores ranging from 3 (deep coma) to 15 (fully awake and alert). A drop in GCS score indicates a significant decline in neurological function, which could be due to increased intracranial pressure, bleeding, or other acute changes in the brain. This requires immediate assessment and intervention to prevent further deterioration.
Choice D Reason:
The client whose deep tendon reflexes have become hyperactive is showing signs of hyperreflexia. Hyperactive reflexes can indicate an upper motor neuron lesion, which affects the descending corticospinal tract. While this is a concerning sign that warrants further investigation, it is not as immediately critical as a sudden change in the GCS score.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: Increased Serum Albumin
Increased serum albumin is not a direct indicator of the therapeutic effect of lactulose in patients with chronic hepatitis. Albumin is a protein made by the liver, and its levels can be affected by liver function. However, lactulose primarily works by reducing ammonia levels in the blood, not by increasing albumin levels. Normal serum albumin levels range from 3.5 to 5.5 grams per deciliter (g/dL). While improved liver function might eventually lead to increased albumin levels, this is not the primary therapeutic effect of lactulose.
Choice B Reason: Decreased Serum Bilirubin
Decreased serum bilirubin is also not a direct indicator of lactulose’s therapeutic effect. Bilirubin is a byproduct of the normal breakdown of red blood cells and is processed by the liver. Elevated bilirubin levels can indicate liver dysfunction, but lactulose’s main role is to reduce ammonia levels, not bilirubin. Normal serum bilirubin levels are typically between 0.1 to 1.2 milligrams per deciliter (mg/dL). While improved liver function might reduce bilirubin levels, this is not the primary goal of lactulose therapy.
Choice C Reason: Decreased Serum Ammonia
Decreased serum ammonia is the correct indicator of the therapeutic effect of lactulose in patients with chronic hepatitis. Lactulose is used to treat hepatic encephalopathy, a condition caused by high levels of ammonia in the blood due to liver dysfunction. Lactulose works by converting ammonia into ammonium, which is then excreted from the body. Normal serum ammonia levels are less than 50 micromoles per liter (µmol/L) in adults56. A decrease in serum ammonia levels indicates that lactulose is effectively reducing the toxic levels of ammonia in the blood, thereby achieving its desired therapeutic effect.
Choice D Reason: Decreased Serum Alanine Aminotransferase (ALT)
Decreased serum alanine aminotransferase (ALT) is not a direct indicator of lactulose’s therapeutic effect. ALT is an enzyme found in the liver that helps convert proteins into energy for liver cells. Elevated ALT levels can indicate liver damage. Normal ALT levels range from 7 to 56 units per liter (U/L). While improved liver function might reduce ALT levels, lactulose’s primary role is to reduce ammonia levels, not directly affect ALT.
Correct Answer is A
Explanation
The correct answer is a) 1 cup of milk.
Choice A reason: One cup of milk contains approximately 15 grams of carbohydrates. Milk is a good source of carbohydrates, protein, and calcium, making it a suitable option for maintaining blood glucose levels during exercise. It is important for individuals with diabetes to monitor their carbohydrate intake to manage their blood sugar levels effectively.
Choice B reason: Half a cup of regular ice cream contains around 15 grams of carbohydrates. However, ice cream also contains high levels of sugar and fat, which may not be the healthiest option for regular consumption, especially for individuals with diabetes. While it can be included occasionally, it is better to choose healthier carbohydrate sources.
Choice C reason: One slice of bread typically contains about 15 grams of carbohydrates. Bread, especially whole grain or whole wheat varieties, can be a good source of carbohydrates for individuals with diabetes. It provides fiber, which helps in maintaining stable blood sugar levels.
Choice D reason: One cup of sugar-free yogurt does not contain 15 grams of carbohydrates. Sugar-free yogurt usually has fewer carbohydrates compared to regular yogurt. It is important to read the nutritional labels to determine the exact carbohydrate content. Regular yogurt, on the other hand, can be a good source of carbohydrates.
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