Neurological Disorders Q 128 - Gyan Darpan : Learning Portal
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Sunday, 17 April 2022

Neurological Disorders Q 128

A client has been pronounced brain dead. Which findings would the nurse assess? Select all that apply.
     A. Decerebrate posturing
     B. Dilated nonreactive pupils
     C. Deep tendon reflexes
     D. Absent corneal reflex

Correct Answer: B, C, & D

A client who is brain dead typically demonstrates nonreactive dilated pupils and nonreactive or absent corneal and gag reflexes. The client may still have spinal reflexes such as deep tendon and Babinski reflexes in brain death. Decerebrate or decorticate posturing would not be seen.

Option A: The physiology of brain death is similar regardless of the etiology. Inadequate tissue oxygenation leads to a progressive cascade of further edema, increasing intracranial pressure, a further decrease in cerebral perfusion and eventual herniation, or complete cessation of blood flow and aseptic necrosis of brain tissue.
Option B: Coma should be evaluated by ensuring a lack of responsiveness to noxious stimuli; no eye or motor reflex should be present in response to stimuli. Additionally, the cause of coma should be identified by neuroimaging, history, and physical examination or laboratory testing.
Option C: Once the decision to proceed with the brain death determination has been made, three conditions must be present: coma, the absence of brainstem reflexes, and apnea. Loss of response to central pain occurs in brain death. Central pain assessment can be by the application of noxious stimuli to certain areas as the supraorbital notch, the ankle of the jaw, upper trapezius, the anterior axillary fold, and the sternum. Neither eye response nor motor reflexes are detectable in brain death.
Option D: The following brainstem reflexes should be tested in the physical examination of a patient deemed for brain death evaluation. They all must be absent for a patient to be diagnosed as brain dead: the pupillary reflex to light–must be fixed at a mid-position; usually, around 4 mm and must not respond to light.

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