A nurse on a neurology unit is assessing a female brain-injured client. The client is unresponsive to speech, and her pupils are dilated and do not react to light. She is breathing regularly, but her respiratory rate is 45 breaths/minute
In response to a noxious stimulus, her arms and legs extend rigidly. What is her level of impairment?
A)
Delirium
B)
Coma
C)
Brain death
D)
Vegetative state
Ans:
B
Feedback:
The continuum of loss of consciousness is marked by the degree of client's responsiveness to stimuli, in addition to the preservation of brain stem reflexes. Since this client still exhibits a pain response (the extended arms and legs indicate decerebrate posturing), even though her pupils are not responsive to light, she has sustained sufficient brain function that she fails to qualify as being brain dead or in a vegetative state.
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