A nurse is starting an intravenous line in a patient being treated for a head injury.Suddenly the patient extends his legs and demonstrates extreme plantar flexion.What action should be taken by the nurse?
A)Document the presence of decorticate posturing.
B)Immediately stop the attempt at intravenous insertion and obtain a blood pressure reading.
C)Assess the position of the patient's arms.
D)Administer intravenous sedation as quickly as possible after access is obtained.

Question

Quizplus · Accepted Answer

The nurse should assess the position of the patient's arms to determine if the posturing is decerebrate, which involves extension of the arms and legs and is a sign of severe brain injury.

A Nurse Is Starting an Intravenous Line in a Patient