A nurse applies a painful stimulus to the nailbeds of an unconscious patient. The patient responds with extension of the arms and legs, pronation of the arms, and plantar flexion. The nurse documents this as:

Decorticate posturing

Flexion withdrawal

Localization of pain

Decerebrate posturing

Answer and Explanation

The Correct Answer is D

Choice A reason:

Decorticate posturing involves abnormal flexion of the arms towards the chest and extension of the legs. This posture indicates damage to the corticospinal tract at the level of the diencephalon. The described response does not match decorticate posturing.

Choice B reason:

Flexion withdrawal is a response to painful stimuli where the patient pulls away or flexes the affected limb. This is a less severe response than posturing and does not match the description provided in the scenario.

Choice C reason:

Localization of pain refers to the patient's ability to purposefully move a hand to the site of a painful stimulus, indicating higher brain function. The described response of arm and leg extension with pronation does not fit this description.

Choice D reason:

Decerebrate posturing is characterized by extension of the arms and legs, pronation of the arms, and plantar flexion. This posture indicates severe brainstem damage and is consistent with the described response.

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Correct Answer is D

Explanation

Choice A reason:

While preparing the gastrointestinal tract for enteral feedings is important, it is not the primary reason for administering famotidine. Famotidine is typically used to reduce gastric acid production, not to prepare the GI tract for feedings.

Choice B reason:

Increasing the motility of the gastrointestinal tract is not the primary function of famotidine. Famotidine is an H2 receptor antagonist that works by decreasing the production of stomach acid.

Choice C reason:

Keeping the gastrointestinal tract functioning normally is a broad statement and does not specifically address the reason for administering famotidine. The drug's role in preventing stress ulcers is more relevant to the patient's current condition.

Choice D reason:

Famotidine is used to prevent stress ulcers, which can occur in critically ill patients, including those on mechanical ventilation. The stress of illness and mechanical ventilation increases the risk of developing gastric ulcers, and famotidine helps reduce this risk by decreasing gastric acid secretion.

A. A 72-year-old client with a brain tumor, GCS of 5 and decerebrate posturing. B. A 24-year-old client after a motor vehicle accident with a Glasgow Coma Scale (GCS) of 3 and no activity on electroencephalogram. C. A 68-year-old male admitted with a massive stroke and GCS of 6. D. A 50-year-old female client after a motor vehicle accident and surgical evacuation of an epidural hematoma, Glasgow Coma Scale 12.

Correct Answer is B

Explanation

Choice A reason:

A 72-year-old client with a brain tumor, GCS of 5, and decerebrate posturing may not be an ideal candidate for organ donation due to age and underlying cancer, which can affect organ viability.

Choice B reason:

A 24-year-old client after a motor vehicle accident with a GCS of 3 and no activity on electroencephalogram is a prime candidate for organ donation. The lack of brain activity indicates brain death, and the patient's young age and otherwise healthy organs make them suitable for transplantation.

Choice C reason:

A 68-year-old male with a massive stroke and GCS of 6 has significant neurological impairment but is not necessarily brain dead. Further evaluation would be required, but this patient may not meet the criteria for brain death necessary for organ donation.

Choice D reason:

A 50-year-old female with a GCS of 12 after surgical evacuation of an epidural hematoma is not an ideal candidate for organ donation at this time as they have a higher level of consciousness and potential for recovery.

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A nurse applies a painful stimulus to the nailbeds of an unconscious patient. The patient responds with extension of the arms and legs, pronation of the arms, and plantar flexion. The nurse documents this as:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is on mechanical ventilation and the client's spouse wonders why famotidine is needed since the client "only has lung problems." What response by the nurse is best?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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