Question

Jane Smith, an 82-year-old female client, was admitted after falling on ice and hitting the back of her head. She is lethargic, but awakens and will talk, but slurs some of her words. She is restless in bed. The LPN/LVN awakened the client to assess her vital signs and perform a neurological assessment. The client stated she has a headache especially in the morning or after she coughs or sneezes that quickly goes away. She turned her head away from the nurse and vomited without any nausea. The nurse needs to provide nursing care to decrease the increased intracranial pressure the client is experiencing.

1. What is the difference between decorticate posturing and decerebrate posturing? Which is worse?
2. Your client has the following assessment findings. Eye Opening to sound only. Verbal Response. The client is grunting and not speaking any words. Motor Response is normal flexion. What is the rating on the Glasgow Coma Scale? What should you do?

Answer 1