The nurse is caring for a patient diagnosed with a traumatic head injury secondary to a work accident.
In the morning assessment, the patient opened his eyes in response to noxious stimuli.
Two hours later, what assessment finding would warrant immediate action by the nurse? The patient:

Can squeeze the nurse's hand upon verbal request.

Follows simple commands with repetition/prompting from nurse.

Has purposeful movement when the nurse rubs the sternum.

Extends upper and lower extremities in response to painful stimuli.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Squeezing the nurse’s hand on verbal request suggests neurological improvement and does not warrant urgent intervention, indicating preserved motor response and cognition.

Choice B rationale

Following commands with repetition/prompting shows mild cognitive delay or reduced processing but does not represent deterioration or life-threatening concern needing immediate action.

Choice C rationale

Purposeful movement to sternal rub implies intact motor response to noxious stimuli. It does not indicate significant neurologic worsening requiring urgent intervention.

Choice D rationale

Extending extremities in response to painful stimuli, known as decerebrate posturing, is a severe neurologic deficit indicating brainstem dysfunction and requires immediate nursing intervention.

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Correct Answer is C

Explanation

Choice A rationale

Monitoring frequency of urination indicates bladder involvement, often related to cystitis. However, it does not indicate ascending progression to the kidneys, which is more severe and requires additional symptoms.

Choice B rationale

Dysuria, or painful urination, typically signifies lower urinary tract infection rather than progression to upper urinary tract infection, such as pyelonephritis. It is not specific to kidney involvement.

Choice C rationale

Flank pain and fever are hallmark symptoms of pyelonephritis, indicating ascending progression of infection from the bladder to the kidneys. These symptoms signal systemic involvement and require immediate medical attention.

Choice D rationale

Pyuria and hematuria are signs of bladder infection but do not indicate progression to kidney infection. These are specific to inflammation or infection in the lower urinary tract.

A. Susceptible host and infectious agent. B. Mode of transmission and portal of entry. C. Infectious agent and reservoir. D. Portal of exit and mode of transmission.

Correct Answer is B

Explanation

Choice A rationale

Susceptible host pertains to the individual's vulnerability to an infectious agent, but handwashing targets the mode of transmission rather than addressing susceptibility or the infectious agent directly.

Choice B rationale

Handwashing interrupts the mode of transmission, preventing pathogens from reaching a portal of entry. This action disrupts the chain of infection and reduces pathogen spread effectively.

Choice C rationale

The infectious agent and reservoir focus on pathogen origination rather than its transfer. Handwashing reduces spread but does not directly address pathogen survival within reservoirs.

Choice D rationale

Portal of exit involves the pathogen leaving the host's body, not its transfer. Handwashing reduces pathogen transmission, specifically addressing its ability to reach a new host.

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The nurse is caring for a patient diagnosed with a traumatic head injury secondary to a work accident.In the morning assessment, the patient opened his eyes in response to noxious stimuli.Two hours later, what assessment finding would warrant immediate action by the nurse? The patient:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has had repeated instances of cystitis.When considering possible ascending progression of the infection, the client should be taught to monitor for:

Correct Answer is C

Explanation

The nurse recognizes that teaching a client to wash the hands after using the bathroom is an attempt to break the chain of infection between the:

Correct Answer is B

Explanation

The client is diagnosed with a transient ischemic attack (TI

The nurse knows that an important contraindication for valproic acid use is:

When considering the pharmacologic management of a patient who has sustained a traumatic head injury, the nurse can anticipate an order for which of the following medications to manage increases in intracranial pressure (ICP)?

The nurse is developing a teaching plan for the client with glaucoma.Which of the following instructions would the nurse include in the plan of care?

The nurse is caring for a patient diagnosed with a brain injury to the cerebellum.Which nursing intervention is priority?

The nurse is preparing to turn the patient who sustained a spinal cord injury.How should the nurse proceed?

The nurse is reviewing discharge instructions for a patient with a spinal cord injury to T-10 going home with an indwelling urinary catheter.What would the nurse emphasize about catheter care? (Select All that Apply.)

A client has had a stapedectomy for otosclerosis 24 hours ago.What must the nurse teach the client about post-operative care?

The nurse is caring for a patient diagnosed with a traumatic head injury secondary to a work accident.
In the morning assessment, the patient opened his eyes in response to noxious stimuli.
Two hours later, what assessment finding would warrant immediate action by the nurse? The patient: