A client is admitted following a motor vehicle collision. When assessing the client's level of consciousness, the nurse notes that the client no longer responds to commands. The nurse initiates a painful stimulus and the client responds by pulling the arms inward with elbows and wrists flexed and extending the legs with the toes pointed downward. Which action should the nurse implement?

Document the purposeful response to pain.

Administer a prescribed PRN analgesic.

Report the finding to the healthcare provider.

Initiate seizure precautions immediately.

Answer and Explanation

The Correct Answer is C

A. Documenting a purposeful response to pain would be appropriate if the client’s movements were purposeful and coordinated, such as reaching toward a stimulus or withdrawing an extremity. However, the described response—arms flexed inward (decorticate posturing) and legs extended with toes pointed downward (decerebrate posturing)—is abnormal posturing indicating severe neurological injury, not purposeful movement. Simply documenting without notifying the provider could delay critical interventions.

B. Administering a PRN analgesic is inappropriate in this scenario. The posturing is neurologically driven, not a response to pain requiring analgesia. Analgesics do not treat the underlying cause, which is likely increased intracranial pressure or severe brain injury.

C. Abnormal posturing (decorticate and decerebrate) is a sign of significant brain injury and possible neurological deterioration. Prompt reporting to the healthcare provider is essential for urgent assessment, possible imaging, and interventions to prevent further neurological compromise, such as managing intracranial pressure or surgical evaluation.

D. Initiating seizure precautions is not immediately indicated. While brain injury increases seizure risk, the observed posturing is not a seizure but a neurological posturing response to painful stimulus. Seizure precautions may be warranted later based on ongoing assessments, but the priority is notifying the healthcare provider.

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Correct Answer is ["A","F"]

Explanation

A. Nitroglycerin is highly susceptible to the "first-pass effect," meaning if it is swallowed or chewed and enters the digestive system, the liver will metabolize and inactivate it before it reaches the heart. It must be administered sublingually (under the tongue) to be absorbed directly into the systemic circulation through the oral mucosa.

B. Nitroglycerin is a potent vasodilator. A common side effect is a sudden drop in blood pressure (orthostatic hypotension), which can cause dizziness, syncope (fainting), and falls. Sitting or lying down before taking the medication ensures patient safety. Additionally, resting reduces the oxygen demand on the heart.

C. Anginal pain often occurs during physical exertion or emotional stress (as seen when the patient was mowing the lawn). Immediate access to the medication is critical to stop the progression of ischemia and prevent myocardial infarction.

D. If the pain does not subside after the first dose, it may indicate a myocardial infarction (heart attack) rather than stable angina. Timely activation of Emergency Medical Services (EMS) is the most critical step in reducing heart muscle damage.

E. In the event the patient becomes unconscious or unresponsive, a medical alert bracelet provides first responders with vital information regarding his cardiac history and medications, allowing for faster and more accurate emergency treatment.

F. This statement contains two errors. First, the interval between doses should be 5 minutes, not 10. Second, the patient should not wait to take three doses before calling 911. Current guidelines suggest calling 911 if pain is unrelieved or worsening 5 minutes after the first dose.

G. Sublingual nitroglycerin typically begins to work within 1 to 3 minutes. Waiting 5 minutes allows enough time for the medication to reach peak effect before deciding if an additional dose or emergency intervention is required.

Correct Answer is ["2216"]

Explanation

Step 1: Convert weight to kilograms
Weight (kg) = 65 ÷ 2.2 ≈ 29.55 kg

Step 2: Calculate dose in units
Dose (units) = Weight × Dose per kg
= 29.55 × 75
≈ 2216.25 units

Step 3: Round to the nearest whole number
≈ 2,216 units

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The nurse has provided discharge teaching to the client to manage his chest pain at home. Which 2 statements from the client should the nurse recognize as a need for further education?

Correct Answer is ["A","F"]

Explanation

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Correct Answer is ["2216"]

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