A nurse is collecting data from a client who has increased intracranial pressure and is informed by the charge nurse that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe?

Extension of the extremities

External rotation of the lower extremities

Pronation of the hands

Plantar ﬂexion of the legs

Answer and Explanation

The Correct Answer is D

a. Decorticate posturing is marked by the flexion of the arms, with the hands clenched into fists and the legs extended and internally rotated.
b. External rotation of the lower extremities is not a characteristic of decorticate posturing. In decorticate posture, legs are held out straight.

c. Pronation of the hands is characteristic of decerebrate posturing, where the arms are extended and pronated.

d. In decorticate posturing, the lower extremities typically exhibit plantar flexion. Additionally, the upper extremities show flexion of the arms, wrists, and fingers with adduction of the arms.

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Correct Answer is C

Explanation

The nurse should monitor the client for ﬂank pain as an adverse eﬀect of taking calcium carbonate. Calcium carbonate is a calcium supplement used to prevent or treat a calcium deficiency¹. One of the side eﬀects of calcium carbonate is the formation of kidney stones, which can cause ﬂank pain².

a. Urinary retention is not a common adverse eﬀect of calcium carbonate.
b. Tinnitus is not a common adverse eﬀect of calcium carbonate.
d. Bradycardia is not a common adverse eﬀect of calcium carbonate.

A. Place a trochanter roll against the thigh. B. Place a sandbag to the lateral calf. C. Place a wedge pillow between the legs. D. Place a footboard on the bed.

Correct Answer is C

Explanation

An appropriate action to prevent hip dislocation in a client who is postoperative following a total hip arthroplasty is to place a wedge pillow between the legs. This helps to maintain proper alignment and prevent the legs from crossing or adducting, which can cause hip dislocation.

Placing a trochanter roll against the thigh, placing a sandbag on the lateral calf, and placing a footboard on the bed are not appropriate actions to prevent hip dislocation in this situation. A trochanter roll is used to prevent the external rotation of the hip. A sandbag to the lateral calf can help prevent foot drop. A footboard can help prevent plantar ﬂexion contractures.

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A nurse is collecting data from a client who has increased intracranial pressure and is informed by the charge nurse that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has osteoporosis and is taking calcium carbonate. The nurse should monitor the client for which of the following adverse eﬀects?

Correct Answer is C

Explanation

A nurse is assisting a client who is postoperative following a total hip arthroplasty into a supine position. Which of the following actions is appropriate to prevent hip dislocation?

Correct Answer is C

Explanation

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