Complete Solutions
Extension of the arms Expected finding in decerebrate posturing.
Elevate the head of the bed Intervention to promote reduction of intracranial pressure.
Use pillows to keep heels off the bed surface Nursing action to prevent skin breakdown in
client with spinal cord injury and paralysis.
Nuchal rigidity Manifestation of increased intracranial pressure in client with suspected
bacterial meningitis.
Brisk pupillary reaction to light Expected finding in infant with motor vehicle crash and
increased intracranial pressure.
Paraplegia Type of disability associated with spinal cord injury at T2-T3 vertebrae.
, Pacemaker spikes before each QRS complex Indication of proper functioning of
ventricular pacemaker.
Hypotension Adverse effect of verapamil, a calcium channel blocker.
Atrial fibrillation Dysrhythmia characterized by rapid and irregular heart rate with no
visible P waves.
Pacemaker spikes before each QRS complex Indication of proper functioning of
ventricular pacemaker.
Defibrillation Priority action for client with ventricular fibrillation.
Irregular pulsations Finding on auscultation of apical pulse in client with premature
ventricular contractions.
Ventricular fibrillation ECG finding in client with sudden onset of irregular palpitations,
fatigue, and dizziness.