Question

The nurse is caring for a client with a head injury. Which of the following assessment findings cause the nurse the most concern? A. Sluggish-to-react pupil B. Negative babinski reflex C. Bilateral decreased hand grips D. Decerebrate posturing

Short answer

Answer: D. Decerebrate posturing

Step-by-step solution

Understand each of the assessment findings

A. Sluggish-to-react pupil: This refers to a pupil that is slow to respond to light stimulus. This could indicate neurological damage, but it's not always the most severe finding. B. Negative Babinski reflex: The Babinski reflex is a normal reflex in infants, but it should be absent in adults. A negative Babinski reflex means that it's absent, so this is a normal finding in an adult. C. Bilateral decreased hand grips: Weakness in both hands may be a sign of a neurological issue, but it could also be related to other factors, such as fatigue, injury, or muscle weakness. It is concerning, but there might be more severe findings. D. Decerebrate posturing: This involves a specific posture where the arms are stiffly extended, the fingers and wrists are bent, and the legs are extended. It is a sign of severe brain damage and requires immediate medical attention.

Identify the most concerning finding

After evaluating the significance of each assessment finding, it is clear that option D, decerebrate posturing, is the most concerning. This is because it is a sign of severe brain damage and requires immediate medical attention. The other findings, while they may also be indicative of neurological issues, are not as severe as decerebrate posturing.

Choose the correct answer

Based on the analysis in Steps 1 and 2, the correct answer is D. Decerebrate posturing is the assessment finding that should cause the nurse the most concern when caring for a client with a head injury.

Key concepts

Decerebrate Posturing

Decerebrate posturing is a type of abnormal body posture that typically indicates a severe brain injury, particularly damage to the brainstem. When a patient exhibits this posture, their arms are stiffly extended by their sides, elbows extended, wrists and fingers flexed, and legs are also extended. This posture indicates a disruption in the brain's control over muscle movements.

Seeing a patient in decerebrate posturing is alarming for healthcare providers because it represents a medical emergency. It's usually caused by conditions that lead to increased intracranial pressure and brain herniation, such as head trauma, stroke, or brain edema. This is a critical finding during a neurological assessment and usually takes precedence over other neurologic indicators when prioritizing patient care.

Neurological Damage Indicators

Neurological damage indicators are clinical signs that suggest damage or dysfunction within the nervous system. These signs are critical when assessing a patient with a potential or known neurological injury. Common indicators include changes in pupil reactivity, reflexes, muscle strength, and posture.

For example, a sluggish-to-react pupil might suggest increased intracranial pressure or damage to the optic nerve. Reflex changes, like a positive Babinski reflex in adults, can be a sign of central nervous system problems. These indicators provide crucial information that healthcare providers use to gauge the severity of neurological damage, guiding immediate treatment decisions and long-term care planning.

NCLEX-RN Examination Preparation

Preparing for the NCLEX-RN examination is a significant step for nursing students to become licensed registered nurses. The NCLEX assesses a candidate's knowledge and abilities to ensure safe and effective nursing practice. Preparation involves studying core nursing content, completing practice questions, and understanding the NCLEX's adaptive testing format.

Students should focus on areas such as pharmacology, medical-surgical nursing, pediatrics, and neurological assessment. It's also essential to develop test-taking strategies and time management skills. Utilizing resources such as NCLEX prep books, online courses, and study groups can help reinforce knowledge and build confidence to succeed on the examination.

Nursing Assessment Findings

Nursing assessment findings are the results of a systematic evaluation performed by a nurse on a patient. These findings encompass various physical, psychological, and social health aspects. For patients with a head injury, assessing neurological function is of paramount importance. This includes checking consciousness levels, pupil reaction to light, motor function, and reflexes.

Aside from decerebrate posturing, other significant assessment findings can include a dilated or non-reactive pupil, which might indicate increased intracranial pressure. Changes in hand grip strength can provide insight into the location and severity of neurological damage. These findings help guide the clinical decision-making process, underlying the importance of a thorough and accurate assessment.