A client is admitted with a brain attack (stroke). On neurologic assessment, a nurse notes that the client's arms, wrists, and fingers have become flexed, and there is internal rotation and plantar flexion of the legs
What would be the nurse's best action? A. Notify the health care team members.
B. Determine the client's advance directive status.
C. Reposition the client to prevent contractures.
D. Document the finding as the only action.
A
The client is demonstrating decorticate posturing that is seen with interruption in the corticospinal pathway. This finding is abnormal, and a sign that the client's condition has deteriorated. The physician, charge nurse, and other team members should be notified immediately of this change in status.
You might also like to view...
A roller sheet has been placed under an elderly client who is receiving treatment for failure to thrive. When using a roller sheet in a client's care, the nurse must
A) Keep the siderails raised to prevent the client from rolling off the side of the bed. B) Ensure that the roller sheet is kept dry and wrinkle-free. C) First ensure that the client is able to roll side-to-side independently. D) Insert an indwelling urinary catheter to protect the roller sheet from urine.
A patient with a diagnosis of thyroid cancer is postoperative day 1 following a total thyroidectomy in which her parathyroid gland was also removed. When assessing for related electrolyte imbalances, what question should the nurse ask the patient?
A) "Do you feel like you're having heart palpitations where your heart feels like it skips a beat?" B) "How thirsty are you feeling right now?" C) "Are you feeling any tingling in your hands or around your mouth?" D) "How would you rate your energy level right now?"
The nurse would include which of the following general guidelines regarding prevention in an educational program for the patient who has experienced a vaginal infection?
A) Wear tight-fitting synthetic underwear. B) Use bubble bath. C) Avoid feminine hygiene products (sprays). D) Restrict daily bathing.
Which of the following groups of clients should not be administered potassium iodide?
A) Those who are allergic to corticosteroids B) Those who are pregnant C) Those who are on medications such as cough medicines D) Those who are allergic to seafood