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Chapter 23: Problem 127

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

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A. Sluggish-to-react pupil B. Negative babinski reflex C. Bilateral decreased hand grips D. Decerebrate posturing Answer: D. Decerebrate posturing

Step by step solution

01

Option A: Sluggish-to-react pupil

Sluggish-to-react pupil might be a sign of increased intracranial pressure due to head injury. While this causes concern, there are other assessment findings that may indicate more significant issues.
02

Option B: Negative babinski reflex

A negative Babinski reflex is a normal finding in adults, as it indicates an intact central nervous system. With head injuries, we would be more concerned with the presence of positive Babinski reflex, which indicates damage to the central nervous system, especially the corticospinal tracts. Option B is not concerning.
03

Option C: Bilateral decreased hand grips

Bilateral decreased hand grips can be concerning as it might indicate damage to the spinal cord or surrounding nerves due to the head injury. Though it is a cause for concern, there is a more alarming assessment finding in this list.
04

Option D: Decerebrate posturing

Decerebrate posturing is the most concerning assessment finding among the given options. It involves abnormal extension and pronation of the upper extremities, and extension of the lower extremities. This can indicate severe brain damage, specifically to the brain stem, and is considered a medical emergency.
05

Conclusion

Based on the analysis, the assessment finding that would cause the nurse the most concern is Option D: Decerebrate posturing, as it indicates severe brain damage and is considered a medical emergency.

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