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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

Kaposi's Sarcoma is a vascular malignancy associated with AIDS caused by human herpesvirus 8. It presents as purple or brown skin lesions due to abnormal angiogenesis and endothelial proliferation in immunocompromised patients.

Choice B rationale

Candidiasis stomatitis typically manifests as white patches on the mucosa due to fungal overgrowth, not purple or brown spots. It is caused by Candida species, commonly seen in immunosuppressed individuals.

Choice C rationale

Cryptosporidiosis primarily leads to gastrointestinal symptoms such as watery diarrhea due to parasitic infection in AIDS patients, but does not cause purple or brown spots on the skin.

Choice D rationale

Meningitis causes inflammation of the meninges, leading to symptoms like headache, stiff neck, and fever. It does not present with purple or brown lesions on the skin.

A. Stabilize the cervical spine until help arrives. B. Control any external bleeding. C. Use the head tilt chin lift method to maintain the airway. D. Do not move the victim from the accident.

Correct Answer is A

Explanation

Choice A rationale

Stabilizing the cervical spine prevents further spinal injury in case of vertebral damage, which is a priority when managing trauma patients until specialized medical care becomes available.

Choice B rationale

While controlling bleeding is essential, it is secondary to stabilizing the cervical spine since the airway and neurological protection take precedence in trauma protocols.

Choice C rationale

The head tilt chin lift method should not be used if cervical spine injury is suspected, as it may exacerbate potential damage to the vertebrae or spinal cord.

Choice D rationale

While not moving the victim is critical, stabilization of the cervical spine is the primary intervention to prevent further injury before emergency assistance arrives.

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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:

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The patient diagnosed with acquired immunodeficiency syndrome (AIDS) states that they have developed purple, brown spots on their body.Which opportunistic infection does the nurse suspect?

Correct Answer is A

Explanation

A nurse is the first person on the scene of a motor vehicle accident.The victim was the driver and is in the driver's seat unconscious.The driver is breathing, has a pulse, and has minor lacerations on the head and face.What action should the nurse implement first?

Correct Answer is A

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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: