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 B
Explanation
Choice A rationale
Non-tender lymph nodes and productive cough are more suggestive of later-stage infections or malignancies, not early HIV presentation which resembles acute viral syndrome.
Choice B rationale
Flu-like symptoms such as chills and aches occur during acute retroviral syndrome due to initial viral replication and immune response shortly after HIV infection.
Choice C rationale
Abdominal cramping and loose stools are associated with gastrointestinal infections in later stages of HIV due to opportunistic pathogens, not acute early-stage presentation.
Choice D rationale
High fever, severe headache, and change in mentation are indicative of central nervous system infections or complications in advanced HIV stages, not early acute HIV symptoms.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Proper nutrition, exercise, and stress reduction enhance psychological well-being, stimulating endorphin release, which improves mood and resilience, essential for managing chronic conditions like HIV.
Choice B rationale
These factors bolster immune function by reducing cortisol levels that impair immunity, supporting T-cell activity and promoting resistance against opportunistic infections common in HIV patients.
Choice C rationale
Maintaining strength and independence aids patients in daily functioning, reducing dependency and enhancing self-efficacy, which is critical for long-term adherence to therapeutic regimens in HIV.
Choice D rationale
Preventing virus transmission requires safe practices, not lifestyle changes alone. Nutrition and exercise cannot alter transmission mechanisms like exposure to body fluids.
Choice E rationale
Eliminating HIV completely necessitates antiretroviral therapy and advancements in medical science; lifestyle modifications alone are insufficient against viral integration within host DNA.
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