A nurse is assessing a client who has suffered a traumatic brain injury. When the nurse applies a stimuli to the client, which of the following responses by the client indicates that the client has suffered an extensive cervical spine injury?

Nystagmus

Decorticate positioning

Lack of any response

Decerebrate positioning

Answer and Explanation

The Correct Answer is D

Choice A Reason: This is incorrect because nystagmus is not a response to stimuli, but a condition that causes involuntary eye movements. Nystagmus can be caused by various factors, such as inner ear disorders, brain lesions, or drug toxicity, but not necessarily by cervical spine injury.

Choice B Reason: This is incorrect because decorticate positioning is a response to stimuli that indicates damage to the cerebral cortex or the corticospinal tract. Decorticate positioning is characterized by flexion of the arms and extension of the legs. It does not indicate cervical spine injury, which affects the spinal cord below the brainstem.

Choice C Reason: This is incorrect because lack of any response to stimuli can indicate various levels of brain damage or coma, but not specifically cervical spine injury. Lack of any response can also be influenced by other factors, such as sedation, hypothermia, or shock.

Choice D Reason: This is correct because decerebrate positioning is a response to stimuli that indicates damage to the brainstem or the upper cervical spine. Decerebrate positioning is characterized by extension and outward rotation of the arms and legs. It indicates a severe and life-threatening injury that can impair vital functions, such as breathing and blood pressure.

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Correct Answer is ["A","B","C"]

Explanation

Choice A Reason: This is a correct choice. Trying to avoid scratching is an advice that the nurse will provide to the client, as it prevents further damage and infection of the skin. Scratching can break the skin barrier and introduce bacteria or fungi into the wound, leading to inflammation and complications.

Choice B Reason: This is a correct choice. Applying a moist cool compress is an advice that the nurse will provide to the client, as it soothes and relieves itching and swelling. A moist cool compress can reduce inflammation and histamine release, which are responsible for allergic symptoms.

Choice C Reason: This is an incorrect choice. Using alcohol to cleanse the area is not an advice that the nurse will provide to the client, as it irritates and dries out the skin. Alcohol can strip away the natural oils and moisture from the skin, making it more prone to cracking and itching.

Choice D Reason: This is an incorrect choice. Using a wooden stick to scratch lesions is not an advice that the nurse will provide to the client, as it causes more harm than good. A wooden stick can injure or infect the skin, as well as spread the allergen or irritant to other areas.

Choice E Reason: This is a correct choice. Avoiding hot air is an advice that the nurse will provide to the client, as it aggravates itching and inflammation. Hot air can increase blood flow and histamine release, which are responsible for allergic symptoms. The client should also avoid hot water or showers, as they can have the same effect.

A. Measure the abdominal girth B. Have the client extend their arms C. Have the client flex and extend their foot D. Ask the client to walk heel to toe

Correct Answer is B

Explanation

Choice A Reason: Measuring the abdominal girth is not related to asterixis, which is a tremor of the hand when the wrist is extended. It may indicate ascites, which is a complication of cirrhosis, but not asterixis.

Choice B Reason: This is the correct choice. Asterixis is a flapping tremor of the hand when the wrist is extended, sometimes said to resemble a bird flapping its wings. It is caused by abnormal function of the diencephalic motor centers that regulate the muscles involved in maintaining posture. It is a sign of hepatic encephalopathy, which is a neuropsychiatric disorder that occurs in patients with liver disease.

Choice C Reason: Having the client flex and extend their foot is not related to asterixis, which affects the hand and wrist. It may test for ankle clonus, which is a rhythmic contraction of the calf muscles when the foot is dorsiflexed. It indicates an upper motor neuron lesion, but not hepatic encephalopathy.

Choice D Reason: Asking the client to walk heel to toe is not related to asterixis, which affects the hand and wrist. It may test for balance and coordination, which can be impaired in patients with hepatic encephalopathy, but it is not a specific sign of asterixis.

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A nurse is assessing a client who has suffered a traumatic brain injury. When the nurse applies a stimuli to the client, which of the following responses by the client indicates that the client has suffered an extensive cervical spine injury?

Nursing Test Bank

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A client who is suffering from an allergic reaction asks the nurse what can be done about the itching. Which of the following will the nurse provide to the client?

Correct Answer is ["A","B","C"]

Explanation

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Correct Answer is B

Explanation

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