A nurse is providing care for a client experiencing obstructive shock. Which of the following diagnoses should the nurse expect?

A. Assess palmar reflex. Assessing the palmar reflex helps evaluate the integrity of the nervous system, particularly in response to tactile stimuli. In clients with severe TBI, abnormal reflexes may indicate neurological impairment and guide further assessment and intervention.

B. Assess for cough reflex. Assessing the cough reflex is important for evaluating airway protection and the risk of aspiration, especially in clients with reduced consciousness level due to TBI.

C. Assess the ability to follow simple commands. Assessing the client's ability to follow simple commands provides valuable information about their level of consciousness and cognitive function. It helps determine the extent of neurological impairment and guides the plan of care, including interventions for communication and cognitive deficits.

D. Assess for Cushing's Triad. Cushing's Triad, characterized by hypertension, bradycardia, and irregular respirations, may occur as a late sign of increased intracranial pressure (ICP) in clients with severe TBI. Monitoring for Cushing's Triad is crucial for early recognition of elevated ICP and prompt intervention to prevent further neurological damage.

E. Assess for abnormal posturing. Assessing for abnormal posturing, such as decerebrate or decorticate posturing, helps evaluate neurological function and localize brain injury in clients with TBI. Abnormal posturing indicates severe brain damage and may guide decisions regarding treatment and prognostication.

Answer: C

Rationale:

A) "I'm glad that I can work remotely from my computer. Prolonged use of a computer can strain the eyes, potentially interfering with the healing process after a retinal reattachment procedure. Clients are generally advised to limit screen time during recovery.

B) "I can't wait to be able to take a bath. Submerging the face in water, as during a bath, is discouraged postoperatively due to the risk of introducing bacteria into the eye and delaying healing. Clients are advised to stick to showers and avoid getting the affected eye wet.

C) "I get bored only being able to watch television. Watching television is usually permissible following retinal surgery, as it does not strain the eye excessively. This statement aligns with typical postoperative instructions.

D) "I will be relieved once I can drive myself to the store." Driving is contraindicated during the recovery phase due to potential visual disturbances and the need for the eye to heal properly. Clients are typically instructed to avoid driving until cleared by their ophthalmologist.