The nurse is caring for a client who had a near-drowning accident in cold weather. Which assessment finding indicates the most severe injury?

Question

Quizplus · Accepted Answer

11ecbb05_cb0a_b66f_b433_6f1f27db1a89_MD0009_00 Near-drowning occurs when a client is under water and unable to breathe for an extended period. In a matter of seconds, major body organs begin to shut down from lack of oxygen and permanent damage results. Decerebrate posturing is a sign of severe brain damage. During assessment, the nurse would observe arms and legs straight out, toes pointed down, and the head/neck arched back. These assessment findings indicate that severe injury has occurred. (Option A) Hypothermia is generally seen in near-drowning victims. One of the first goals of treatment is to warm the client. This is done using warmed IV fluids, blankets, and air. Sustained hypothermia will eventually lead to organ failure, making this an urgent finding but not initially life-threatening. (Option C) A weak and thready pulse is generally detected in near-drowning victims due to hypothermia. Once the client is properly warmed, the pulse generally returns to normal. Sometimes the client is so cold that a pulse cannot be detected; this is why a client is not dead until warm and dead. Such clients may require prolonged resuscitation. (Option D) When wheezing is heard on auscultation after a near-drowning, the first observation would be that the client is still moving air and providing oxygen to the body. The wheezing may indicate that the client has bronchospasm. If the client has aspirated fluid, crackles would be heard. Most such clients will develop acute respiratory distress syndrome. Educational objective: Decerebrate posturing (arms and legs straight out, toes pointed down, head/neck arched back) usually indicates severe brain injury.

The Nurse Is Caring for a Client Who Had a Near-Drowning