The nurse has just received a report on a group of clients on the neurosurgical unit. Which client is the nurse’s first priority?

Client who displays plantar flexion when the bottom of the foot is stroked.

Client who consistently demonstrates decortication when stimulated.

Client whose Glasgow Coma Scale (GCS) has changed from 15 to 12.

Client whose deep tendon reflexes have become hyperactive.

Answer and Explanation

The Correct Answer is C

Choice A Reason:

The client who displays plantar flexion when the bottom of the foot is stroked is exhibiting a normal reflex response known as the plantar reflex. This response indicates that the corticospinal tract is functioning properly. In adults, the normal response is plantar flexion of the toes, which means the toes curl downward. This is not an immediate cause for concern and does not indicate a life-threatening condition.

Choice B Reason:

The client who consistently demonstrates decortication when stimulated is showing signs of severe brain injury. Decorticate posturing is characterized by the arms being flexed at the elbows and held tightly to the chest, with the legs extended and feet turned inward. This type of posturing indicates damage to the cerebral hemispheres, thalamus, or midbrain. While this is a serious condition, it is not necessarily the most immediate priority compared to a sudden change in the Glasgow Coma Scale.

Choice C Reason:

The client whose Glasgow Coma Scale (GCS) has changed from 15 to 12 is the nurse’s first priority. The GCS is a critical tool used to assess a patient’s level of consciousness, with scores ranging from 3 (deep coma) to 15 (fully awake and alert). A drop in GCS score indicates a significant decline in neurological function, which could be due to increased intracranial pressure, bleeding, or other acute changes in the brain. This requires immediate assessment and intervention to prevent further deterioration.

Choice D Reason:

The client whose deep tendon reflexes have become hyperactive is showing signs of hyperreflexia. Hyperactive reflexes can indicate an upper motor neuron lesion, which affects the descending corticospinal tract. While this is a concerning sign that warrants further investigation, it is not as immediately critical as a sudden change in the GCS score.

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Correct Answer is F

Explanation

Assessment: Patient had 2 semi-formed bowel movements 1 hour after administration of the medication

Choice A Reason:

Assessment: Patient denies vomiting

This choice is not directly related to the effectiveness of Kayexalate. Vomiting can be a symptom of hyperkalemia, but the absence of vomiting does not indicate that the medication is working. Kayexalate works by binding potassium in the intestines and removing it through the stool, so the presence of bowel movements is a more direct indicator of its effectiveness.

Choice B Reason:

ECG: Flattening of QRS complex angle

Flattening of the QRS complex angle is not a typical ECG change associated with hyperkalemia or its treatment. Hyperkalemia typically causes widening of the QRS complex, and effective treatment would normalize this. Therefore, this choice is not correct.

Choice C Reason:

ECG: Widening of the QRS complex

Widening of the QRS complex is a sign of hyperkalemia, not its resolution. If the medication is effective, the QRS complex should return to a normal width. Therefore, this choice is not correct.

Choice D Reason:

Assessment: Patient consumed 60% of meal

While nutritional intake is important, it is not a direct indicator of the effectiveness of Kayexalate. The medication’s effectiveness is better assessed by changes in potassium levels and related symptoms, not by meal consumption.

Choice E Reason:

Assessment: Patient denies nausea

Similar to vomiting, nausea can be a symptom of hyperkalemia, but the absence of nausea does not indicate that the medication is working. The effectiveness of Kayexalate is better assessed by the presence of bowel movements and changes in potassium levels.

Choice F Reason:

Assessment: Patient had 2 semi-formed bowel movements 1 hour after administration of the medication

This is the correct answer. Kayexalate works by binding potassium in the intestines and removing it through the stool. The presence of bowel movements indicates that the medication is working to remove potassium from the body. This is a direct and relevant assessment finding.

Choice G Reason:

ECG: Shortening of P wave duration

Shortening of the P wave duration is not a typical ECG change associated with hyperkalemia or its treatment. Therefore, this choice is not correct.

Choice H Reason:

Assessment: Patient denies pain

Pain is not a typical symptom of hyperkalemia, and its absence does not indicate that the medication is working. Therefore, this choice is not correct.

Choice I Reason:

ECG: Reduction of T wave amplitude

Reduction of T wave amplitude can be a sign of hypokalemia, not hyperkalemia. Effective treatment of hyperkalemia would normalize the T wave amplitude, not reduce it. Therefore, this choice is not correct.

A. Hemoptysis B. High-pitched holosystolic murmur C. Hepatomegaly

Correct Answer is A

Explanation

Choice A Reason:

Hemoptysis, or coughing up blood, is a common feature of both mitral valve stenosis and mitral valve regurgitation. In mitral valve stenosis, the narrowing of the valve leads to increased pressure in the pulmonary veins, which can cause pulmonary congestion and hemoptysis. Similarly, in mitral valve regurgitation, the backflow of blood into the left atrium increases pulmonary pressure, potentially leading to pulmonary edema and hemoptysis. Therefore, hemoptysis is a shared symptom of both conditions.

Choice B Reason:

A high-pitched holosystolic murmur is more commonly associated with mitral valve regurgitation rather than mitral valve stenosis. In mitral valve regurgitation, the murmur is caused by the backflow of blood from the left ventricle into the left atrium during systole3. Mitral valve stenosis, on the other hand, typically presents with a diastolic murmur due to the turbulent flow of blood through the narrowed valve during diastole. Therefore, a high-pitched holosystolic murmur is not a common feature of both disorders.

Choice C Reason:

Hepatomegaly, or an enlarged liver, can occur in advanced cases of both mitral valve stenosis and mitral valve regurgitation due to right-sided heart failure. However, it is not a primary or common feature of these conditions. Hepatomegaly is more often associated with conditions that directly affect the right side of the heart or cause systemic congestion. Therefore, hepatomegaly is not a common feature of both mitral valve stenosis and mitral valve regurgitation.

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The nurse has just received a report on a group of clients on the neurosurgical unit. Which client is the nurse’s first priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is F

Explanation

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Correct Answer is A

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