A client presents with superficial burns and multiple intact blisters on the forearm.
During dressing change, several blisters rupture and the underlying skin is exposed. Which action should the nurse take?

A hypophysectomy involves the surgical removal of the pituitary gland. Knowledge of endocrine physiology is required to understand the postoperative loss of posterior pituitary hormones and the necessity of exogenous replacement therapy to maintain fluid balance and prevent complications.

Choice A rationale

Syndrome of inappropriate antidiuretic hormone involves excessive ADH, whereas hypophysectomy results in a total deficiency. Vasopressin is given to prevent the opposite condition, diabetes insipidus, characterized by massive polyuria and severe fluid volume deficit.

Choice B rationale

The posterior pituitary stores and secretes antidiuretic hormone (ADH), also known as vasopressin. Removal of the gland eliminates the body's ability to concentrate urine, necessitating hormonal replacement to regulate water reabsorption in the kidneys.

Choice C rationale

Vasopressin is not primarily used to treat cerebral edema or intracranial pressure. While it affects fluid volume, medications like mannitol or corticosteroids are the standard pharmacological interventions for managing postoperative cerebral swelling and elevated pressure.

Choice D rationale

Vasopressin is an antidiuretic hormone, not a growth hormone. Growth failure is treated with somatropin. While pituitary removal stops growth hormone production, the immediate life-threatening concern postoperatively is the management of massive water loss.

Neurological assessment using motor responses helps determine the level of brainstem involvement. This scenario requires applying knowledge of the Glasgow Coma Scale and motor pathways to distinguish between pathological posturing and more integrated, purposeful motor functions.

Choice A rationale

Purposeful movement indicates that the motor cortex or higher brain centers are successfully processing stimuli. Moving away from pain represents a significant improvement from decorticate posturing, which involves damage to the corticospinal tract and midbrain.

Choice B rationale

Decerebrate posturing involves rigid extension of the arms and legs, signifying deeper brainstem injury or herniation. This change indicates neurological deterioration rather than improvement, as it suggests the lesion has progressed lower into the pons.

Choice C rationale

Pupils that are fixed and dilated at 6 mm indicate loss of autonomic function and severe cranial nerve III compression. This is a sign of increasing intracranial pressure and brainstem failure, representing a critical clinical decline.

Choice D rationale

Flaccid paralysis is often the most severe motor finding, indicating a loss of all muscle tone and spinal reflex arcs. In the context of traumatic brain injury, this usually signals profound neurological collapse rather than recovery..