A nurse is caring for a client with a severe traumatic brain injury who is receiving mechanical ventilation via tracheostomy. During assessment, the client extends both arms and legs, arches the head back, and exhibits internal rotation of the wrists in response to painful stimuli.
A nurse is caring for a client with a severe traumatic brain injury who is receiving mechanical ventilation via tracheostomy. During assessment, the client extends both arms and legs, arches the head back, and exhibits internal rotation of the wrists in response to painful stimuli.
A. Reposition the client to a left lateral position
[7%]
B. Elevate the head of the bed to 90 degrees
[5%]
C. Suction the tracheostomy
[10%]
D. Notify the client’s primary health care provider
[78%]
Statistics
Subject/Lesson
Subject
Critical Care
Lesson
Critical Care Concepts
Client Need
Test Plan
Physiological Adaptation
Related Topic
Alterations in Body Systems
Item Type
Item Type
Application
Explanation
Choice D is correct. The client is exhibiting decerebrate posturing, a sign of severe brainstem injury and increased intracranial pressure (ICP). This is a neurologic emergency that requires immediate provider notification for potential interventions to prevent herniation or further brain injury.
Choice A is incorrect. While lateral positioning can help with secretion drainage, it is not an appropriate or priority intervention in the presence of neurologic deterioration. Posturing requires rapid neuro response, not routine repositioning.
Choice B is incorrect. Elevating to 90 degrees is contraindicated; it may lower cerebral perfusion pressure (CPP) and compromise cerebral blood flow. The standard for ICP management is 30° elevation, not extreme upright positioning.
Choice C is incorrect. Suctioning is appropriate for airway management, but does not address the neurologic emergency indicated by posturing. There is no cue of respiratory distress or secretion-related compromise in this scenario.
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2 Key Topics
Posturing- Critical Care
27.2 Critical Care Neurovascular System
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