A nurse is caring for a client who has a head injury. The client states they fell off a ladder while painting approximately 2 hours ago and lost consciousness for 45 minutes according to their partner. The nurse should determine that the client is experiencing which of the following classifications of traumatic brain injury?

Choice A reason: Flexing the upper and extending the lower extremities in response to the painful stimulus is not an expected response for a client who has a traumatic head injury. This is a sign of decorticate posturing, which indicates damage to the cerebral hemispheres or the internal capsule. Decorticate posturing is a type of abnormal flexion that involves the abduction of the arms, internal rotation of the shoulders, flexion of the wrists, and extension of the legs.

Choice B reason: Pushing the painful stimulus away is not an expected response for a client who has a traumatic head injury. This is a sign of normal motor function, which indicates that the client can localize and withdraw from the painful stimulus. This is the highest level of motor response on the Glasgow Coma Scale (GCS), which is a neurological scoring system used to assess conscious level after head injury.

Choice C reason: Extending the body toward the painful stimulus is an expected response for a client who has a traumatic head injury. This is a sign of decerebrate posturing, which indicates damage to the brainstem or midbrain. Decerebrate posturing is a type of abnormal extension that involves the abduction of the arms, external rotation of the shoulders, extension of the wrists, and extension of the legs.

Choice D reason: Showing no reaction to the painful stimulus is not an expected response for a client who has a traumatic head injury. This is a sign of flaccid paralysis, which indicates damage to the spinal cord or peripheral nerves. Flaccid paralysis is a type of complete loss of muscle tone and reflexes that involves the absence of any voluntary or involuntary movements.

Choice A reason: Encourage the use of wide grip utensils. This action is not related to homonymous hemianopsia, but to the motor weakness or paralysis that may occur on the opposite side of the body after a stroke. Wide grip utensils can help the client hold and use them more easily.

Choice B reason: Remind the client to look for food on the left side of the tray. This action is appropriate because homonymous hemianopsia is a visual field loss on the same side of both eyes. A client who had a right sided stroke will have difficulty seeing the left side of their visual field. Reminding the client to look for food on the left side of the tray will help them eat more completely and prevent malnutrition.

Choice C reason: Provide a nonskid mat to alleviate plate movement. This action is not related to homonymous hemianopsia, but to the safety and stability of the client's eating environment. A nonskid mat can prevent the plate from sliding or falling off the tray.

Choice D reason: Encourage the client to use his right hand when feeding himself. This action is not related to homonymous hemianopsia, but to the motor weakness or paralysis that may occur on the opposite side of the body after a stroke. Encouraging the client to use his right hand can help him maintain his independence and function.