Nokea
The nurse is assessing the client following a closed head injury. When applying nailbed pressure, the client’s body suddenly stiffens, the eyes roll upward, and there is an increase in salivation and loss of swallowing reflex. Which observation should the nurse document?
- A. Decerebrate posturing observed
- B. Decorticate posturing observed
- C. Positive Kernig’s sign observed
- D. Seizure activity observed
Correct Answer: D
Rationale: Decerebrate posture involves rigid extension of the arms and legs, downward pointing of the toes, and backward arching of the head. Decorticate posture involves rigidity, flexion of the arms toward the body with the wrists and fingers clenched and held on the chest, and the legs extended. A positive Kernig’s sign is flexing the leg at the hip and then raising the leg into extension. Severe head and neck pain occurs. Body stiffening, eyes rolled upward, increase in salivation, and a loss of swallowing reflex are signs consistent with the tonic phase of a tonic-clonic seizure. This phase is followed by the clonic phase with violent muscle contractions.
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The client diagnosed with a brain tumor has a diminished gag response and weakness on the left side of the body. Which intervention should the nurse implement?
- A. Make the client NPO until seen by the health-care provider.
- B. Position the client in low Fowler’s position for all meals.
- C. Place the client on a mechanically ground diet.
- D. Teach the client to direct food and fluid toward the right side.
Correct Answer: A
Rationale: A diminished gag reflex increases aspiration risk, so making the client NPO (A) is safest until swallowing is evaluated. Low Fowler’s (B) increases aspiration risk, a ground diet (C) is premature, and directing food (D) requires intact swallowing.
The nurse is assessing the client admitted with encephalitis. Which data require immediate nursing intervention? The client has bilateral facial palsies.
- A. The client has a recurrent temperature of 100.6°F.
- B. The client has a decreased complaint of headache.
- C. The client comments that the meal has no taste.
Correct Answer: B
Rationale: A fever of 100.6°F (B) in encephalitis may indicate worsening infection or inflammation, requiring immediate intervention. Decreased headache (C) suggests improvement, and taste loss (D) is less urgent. Facial palsies are noted but not an option.
The nurse is enjoying a day at the lake and witnesses a water skier hit the boat ramp. The water skier is in the water not responding to verbal stimuli. The nurse is the first health-care provider to respond to the accident. Which intervention should be implemented first?
- A. Assess the client's level of consciousness.
- B. Organize onlookers to remove the client from the lake.
- C. Perform a head-to-toe assessment to determine injuries.
- D. Stabilize the client's cervical spine.
Correct Answer: D
Rationale: In trauma with potential head or neck injury, stabilizing the cervical spine (D) is the first priority to prevent spinal cord injury during movement. Assessing consciousness (A), organizing removal (B), or performing a full assessment (C) follows.
The nurse assesses the client, who was injured in a diving accident 2 hours earlier. The client is breathing independently but has no movement or muscle tone from below the area of injury. A CT scan reveals a fracture of the C4 cervical vertebra. The nurse should plan interventions for which problem?
- A. Complete spinal cord transection
- B. Spinal shock
- C. An upper motor neuron injury
- D. Quadriplegia
Correct Answer: B
Rationale: A complete spinal cord transection results in no reflexes or movement distal to the injury. With a C4 injury, the client initially would have some difficulty breathing due to edema of the spinal cord that occurs above the level of the injury. The client is experiencing spinal shock that manifests within a few hours after the injury. Hypotension, flaccid paralysis, and absence of muscle contractions occur. Spinal shock lasts 7 to 20 days, and the SCI cannot be classified accurately until spinal shock resolves. An injury of the upper motor neuron results in spastic paralysis. Quadriplegia, now termed tetraplegia, is paralysis involving all four extremities.
The nurse is caring for clients on the rehabilitation unit. Which clients should the nurse assess first after receiving the change-of-shift report?
- A. The client with a C6 SCI who is complaining of dyspnea and has crackles in the lungs.
- B. The client with an L4 SCI who is crying and very upset about being discharged home.
- C. The client with an L2 SCI who is complaining of a headache and feeling very hot.
- D. The client with a T4 SCI who is unable to move the lower extremities.
Correct Answer: A
Rationale: Dyspnea and crackles in a C6 SCI patient (A) suggest respiratory compromise, a life-threatening condition requiring immediate assessment. Emotional distress (B), headache (C), or expected paralysis (D) are less urgent.