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 D

Explanation

The nurse should immediately report small drops of clear ﬂuid in the left ear to the charge nurse. This finding could indicate a cerebrospinal ﬂuid (CSF) leak, which can occur as a result of a head injury. A CSF leak can be a serious medical condition that requires immediate attention.

An edematous bruise on the forehead, client disorientation to place, and a heart rate of 110/min and regular are also important findings that the nurse should report to the charge nurse. However, these findings are not as urgent as the presence of small drops of clear ﬂuid in the left ear.

A. Move the right crutch about 10 to 15 cm (4 to 6 in). B. Move the left foot forward. C. Move the left crutch forward. D. Move the right foot forward.

Correct Answer is A,B,C,D

Explanation

The order of the steps for the four-point alternate gait with crutches is as follows: move the right crutch about 10 to 15 cm (4 to 6 in), move the left foot forward, move the left crutch forward, and move the right foot forward. This gait patern provides maximum stability and support for the client by keeping three points of contact on the ground at all times.

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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

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Explanation

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Explanation

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