Neurological Question #45

Question

The nurse is caring for a client who has been unconscious and ventilator dependent in the intensive care unit for 6 days. The last three electroencephalograms revealed no brain wave activity, and the health provider pronounces the client with brain death. During assessment, the nurse documents which findings? (Select all that apply)

Answers

  1. Blink reflex intact.
    • Rationale:
  2. Decerebrate posturing is present.
    • Rationale:
  3. Nonreactive dilated pupils.
    • Rationale:
  4. Gag reflex is absent.
    • Rationale:

Overview

Explanation

A client on life support and is brain dead will have nonreactive pupillary response and absent gag reflex, along with corneal and blink reflexes. There may still be signs of spinal reflexes such as deep tendon and babinski reflexes. Decerebrate posturing is absent in brain death and reflects absence of brain-stem activity found in brain death. Few cases have seen a type of decerebrate response; however, they are rare and usually reflect spinal origin instead of brain stem origin. Criteria in establishing brain death require absence of all brainstem-mediated reflexes including motor posturing. Spinal cord automations may still emerge.

Learning Outcomes

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