The nurse is caring for a patient diagnosed with a traumatic head injury secondary to a work accident.
In the morning assessment, the patient opened his eyes in response to noxious stimuli.
Two hours later, what assessment finding would warrant immediate action by the nurse? The patient:
Can squeeze the nurse's hand upon verbal request.
Follows simple commands with repetition/prompting from nurse.
Has purposeful movement when the nurse rubs the sternum.
Extends upper and lower extremities in response to painful stimuli.
The Correct Answer is D
Choice A rationale
Squeezing the nurse’s hand on verbal request suggests neurological improvement and does not warrant urgent intervention, indicating preserved motor response and cognition.
Choice B rationale
Following commands with repetition/prompting shows mild cognitive delay or reduced processing but does not represent deterioration or life-threatening concern needing immediate action.
Choice C rationale
Purposeful movement to sternal rub implies intact motor response to noxious stimuli. It does not indicate significant neurologic worsening requiring urgent intervention.
Choice D rationale
Extending extremities in response to painful stimuli, known as decerebrate posturing, is a severe neurologic deficit indicating brainstem dysfunction and requires immediate nursing intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
A decreased level of consciousness indicates possible intracranial hemorrhage, a complication of thrombolytic therapy. Altered mental status may result from brain bleeding disrupting normal neural function.
Choice B rationale
Elevated blood pressure and headache suggest intracranial hemorrhage, as the rise in intracranial pressure often accompanies vascular disruption and neurogenic pain.
Choice C rationale
Vomiting and persistent nausea can signal intracranial hemorrhage, as blood irritating brain tissue and increasing pressure stimulates the emetic center in the medulla.
Choice D rationale
Positive Babinski's sign is associated with upper motor neuron lesions but is not a direct indicator of thrombolytic therapy complications such as intracranial bleeding.
Choice E rationale
Fever and cardiac dysrhythmias do not directly indicate thrombolytic therapy complications. Dysrhythmias may stem from electrolyte disturbances or infections unrelated to hemorrhage.
Correct Answer is D
Explanation
Choice A rationale
Scheduled voiding relies on the patient’s ability to control bladder function, which is ineffective in cases of a flaccid bladder caused by spinal cord injuries.
Choice B rationale
External catheters, such as condom catheters, are suited for patients with partial bladder control but are not appropriate for flaccid or atonic bladder management.
Choice C rationale
Indwelling urinary catheters may be used short-term but pose higher risks of urinary tract infections and are not optimal for long-term management of flaccid bladder.
Choice D rationale
Intermittent catheterization is the preferred method for managing flaccid bladder, ensuring complete bladder emptying while minimizing infection risks compared to indwelling catheters.
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