MED SURG III - EXAM #2

Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities?

• Normal

• Decerebrate

• Flaccid

• Decorticate

Answer explanation

Rationale:Decorticate posturing is an abnormal posture associated with severe brain injury, characterized by abnormal flexion of the upper extremities and extension of the lower extremities. Decerebration is an abnormal body posture associated with a severe brain injury, characterized by extreme extension of the upper and lower extremities. Flaccidity occurs when the client has no motor function, is limp, and lacks motor tone.

A Glasgow Coma Scale (GCS) score of 7 or less is generally interpreted as

• Coma

• Most Responsive

• Least Responsive

• A need for emergency attention

Answer explanation

Rationale:The Glasgow Coma Scale (GCS) is a tool for assessing a client's response to stimuli. A score of 7 or less is generally interpreted as coma. A GCS score of 10 or less indicates a need for emergency attention. A GCS score of 3 is interpreted as least responsive; a score of 15 is interpreted as most responsive.

Which stimulus is known to trigger an episode of autonomic dysreflexia in the client who has suffered a spinal cord injury?

• Diarrhea

• Placing the client in a sitting position

• Voiding

• Placing a blanket over a client

Answer explanation

Rationale:An object on the skin or skin pressure may precipitate autonomic dysreflexia. In general, constipation or fecal impaction triggers autonomic dysreflexia. When the client is observed to be demonstrating signs of autonomic dysreflexia, the nurse immediately places the client in a sitting position to lower blood pressure. The most common cause of autonomic dysreflexia is a distended bladder.

The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)?

• Maintain cerebral perfusion pressure from 50 to 70 mm Hg

• Administer enemas, as needed

• Restrain the client, as indicated

• Position the client in the supine position

Answer explanation

Rationale:The nurse should maintain cerebral perfusion pressure from 50 to 70 mm Hg to help control increased ICP. Other measures include elevating the head of the bed as prescribed, maintaining the client's head and neck in neutral alignment (no twisting or flexing the neck), initiating measures to prevent the Valsalva maneuver (e.g., stool softeners), maintaining body temperature within normal limits, administering O2 to maintain PaO2 greater than 90 mm Hg, maintaining fluid balance with normal saline solution, avoiding noxious stimuli (e.g., excessive suctioning, painful procedures), and administering sedation to reduce agitation.

When the nurse observes that the client has extension and external rotation of the arms and wrists and plantar flexion of the feet, the nurse records the client's posture as

• Flaccid

• Decerebrate

• Decorticate

• Normal

Answer explanation

Rationale:Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing. The client's head and neck arch backward, and the muscles are rigid. In decorticate posturing, which results from damage to the nerve pathway between the brain and spinal cord and is also very serious, the client has flexion and internal rotation of the arms and wrists, as well as extension, internal rotation, and plantar flexion of the feet.

The nurse is caring for a client with traumatic brain injury (TBI). Which clinical finding, observed during the reassessment of the client, causes the nurse the most concern?

• Heart rate decrease from 100 to 90 bpm

• Temperature increase from 98.0°F to 99.6°F

• Pulse oximetry decrease from 99% to 97% room air

• Urinary output increase from 40 to 55 mL/hr

Answer explanation

Rationale:Fever in the client with a TBI can be the result of damage to the hypothalamus, cerebral irritation from hemorrhage, or infection. The nurse monitors the client's temperature every 2 to 4 hours. If the temperature increases, efforts are made to identify the cause and to control it using acetaminophen and cooling blankets to maintain normothermia. The other clinical findings are within normal limits.

The nurse in the neurological unit is monitoring a client with a head injury for signs of increased intracranial pressure (ICP). The nurse reviews the assessment findings for the client and notes documentation of the presence of Cushing's reflex. The nurse determines that the presence of this reflex is obtained by assessing which item?

• Blood pressure

• Pupillary response

• Motor response

• Level of consciousness

Answer explanation

Cushing's reflex is a late sign of increased ICP and consists of a widening pulse pressure (systolic pressure rises faster than diastolic pressure) and bradycardia. The remaining options are unrelated to monitoring for Cushing's reflex.

The nurse is caring for a client who sustained a spinal cord injury. During administration of morning care, the client begins to exhibit signs and symptoms of autonomic dysreflexia. Which initial nursing action would the nurse take?

• Elevate the head of the bed

• Assess the client's BP

• Examine the rectum digitally

• Place the client in the prone position

Answer explanation

Autonomic dysreflexia is a serious complication that can occur in the spinal cord–injured client. Once the syndrome is identified, the nurse elevates the head of the client's bed and then examines the client for the source of noxious stimuli. The nurse also assesses the client's blood pressure, but the initial action would be to elevate the head of the bed. The client would not be placed in the prone position; lying flat will increase the client's blood pressure.

The client with a head injury opens eyes to sound, has no verbal response, and localizes to painful stimuli when applied to each extremity. How would the nurse document the Glasgow Coma Scale (GCS) score?

• 3

• 6

• 9

• 11

Answer explanation

The GCS is a method for assessing neurological status. The highest possible GCS score is 15. A score lower than 8 indicates that coma is present. Motor response points are as follows: Obeys a simple response = 6; Localizes painful stimuli = 5; Normal flexion (withdrawal) = 4; Abnormal flexion (decorticate posturing) = 3; Extensor response (decerebrate posturing) = 2; No motor response to pain = 1. Verbal response points are as follows: Oriented = 5; Confused conversation = 4; Inappropriate words = 3; Responds with incomprehensible sounds = 2; No verbal response = 1. Eye opening points are as follows: Spontaneous = 4; In response to sound = 3; In response to pain = 2; No response, even to painful stimuli = 1. Using the GCS, a score of 3 is given when the client opens the eyes to sound. Localization to pain is scored as 5. When there is no verbal response, the score is 1. The total score is then equal to 9.

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure (ICP). Pending specific primary health care provider prescriptions, the nurse would place the client in which positions? Select all that apply.

• Head midline

• Flat, with head turned to the side

• Head of bed elevated with the neck extended

• Neck in neutral position

• Head of bed elevated 30 to 45 degrees

Answer explanation

The client who is at risk for or who has increased ICP would be positioned so that the head is in a neutral, midline position. The nurse would avoid flexing or extending the client's neck or turning the head from side to side. The head of the bed needs to be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep ICP down.