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 A

Explanation

Choice A rationale

Vigorous coughing or nose blowing increases pressure in the middle ear, potentially dislodging the stapes prosthesis, interfering with healing, and increasing risk of complications like vertigo or auditory damage.

Choice B rationale

Packing with dry dressing is contraindicated because it may trap moisture and increase infection risk. If drainage occurs, sterile measures are taken to assess and manage infection without creating ideal conditions for pathogens.

Choice C rationale

Irrigation of the ear canal risks introducing pathogens or disrupting the surgical area. Post-surgery, maintaining a dry environment helps reduce infection and promote proper healing.

Choice D rationale

Though bedrest may be recommended initially, prolonged immobility isn't essential unless specific complications arise. Movement minimizes risks of clot formation and encourages circulation, aiding recovery.

A. My heart rate will no longer be irregular. B. This medication will help lower my blood pressure. C. I will have decreased pain to my legs when I walk. D. Clopidogrel will prevent clots from forming.

Correct Answer is D

Explanation

Choice A rationale

Clopidogrel is an antiplatelet agent that prevents platelet aggregation but does not affect arrhythmias. It reduces clot formation risk, which is critical for patients with a history of TIA or stroke.

Choice B rationale

Clopidogrel does not lower blood pressure. It works by inhibiting platelet aggregation to prevent thrombus formation, not addressing the mechanisms of hypertension or blood pressure control.

Choice C rationale

Clopidogrel does not directly affect peripheral artery disease symptoms, such as leg pain. It is used to reduce the risk of thrombotic events like strokes and heart attacks by preventing platelet aggregation.

Choice D rationale

Clopidogrel inhibits platelet aggregation by blocking the ADP receptor on platelets, reducing the risk of clot formation. This is crucial for preventing ischemic events in patients with a history of TIA.

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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:

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is A

Explanation

The client is diagnosed with a transient ischemic attack (TI

Correct Answer is D

Explanation

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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: