A nurse is caring for a client who has a brain tumor. The client displays decorticate posturing in response to painful stimuli. Which of the following images illustrates decorticate posturing?

 

 

 

A. Obtain a radial pulse.: Assessing the radial pulse does not help control active bleeding and does not address the immediate risk associated with hemophilia. Circulatory checks may be useful later, but they do not stop hemorrhage. The priority is to control bleeding before moving to assessment tasks.

B. Maintain direct pressure over the site.: Clients with hemophilia have impaired clotting and require sustained direct pressure to help slow bleeding. Continuous pressure supports platelet plug formation and reduces blood loss from even minor injuries. This action directly targets the immediate threat and is the most effective next step.

C. Reinforce the dressing over the site.: Adding more dressing does not exert the pressure needed to stop bleeding in hemophilia. Reinforcement may absorb more blood but will not help form a clot or reduce active bleeding. This delays the correct intervention and can allow further blood loss.

D. Check whether the bleeding has stopped.: Checking too soon interrupts clot formation, which is especially fragile in clients with clotting disorders. Lifting the dressing to inspect can dislodge early clots and worsen hemorrhage. Bleeding must be controlled first through sustained, uninterrupted pressure.

• Determine if the nasogastric tube is in the correct position: The client reports nausea and the NG tube is not draining, which may indicate malposition or blockage. Verifying tube placement is the priority because improper placement can cause ineffective decompression, aspiration, or injury to the gastrointestinal tract.

• Request a prescription for an antiemetic: Administering an antiemetic may mask symptoms without addressing the underlying issue of a nonfunctional NG tube. Treating nausea alone does not resolve the obstruction or improve decompression.

• Increase the nasogastric tube suction: Increasing suction before confirming proper tube placement may cause injury or irritation to the gastric mucosa and does not guarantee effective drainage if the tube is malpositioned or blocked.

• Repositioning the nasogastric tube: If the tube is correctly placed but not draining, repositioning can help restore patency and proper gastric decompression. This ensures relief from nausea, prevents further distention, and maintains electrolyte balance.

• Placing the client in semi-Fowler's position: While semi-Fowler’s may help reduce risk of aspiration and improve comfort, it does not address the primary problem of a nonfunctional NG tube and should follow verification and repositioning.

• Providing the client with mouth care: Mouth care is important for comfort and infection prevention, but it does not address the urgent problem of nausea and impaired gastric decompression.