A nurse is doing rounds and notes a patient in the following position: How would the nurse document this finding?

Spinal cord degeneration

Decorticate posturing

Atypical hyperreflexia

Decerebrate posturing

Answer and Explanation

The Correct Answer is D

A.   Spinal cord degeneration is a general term for the deterioration of the spinal cord and doesn't specifically describe the patient's posture.
B.   Decorticate posturing is characterized by the arms flexed and adducted, with the wrists and fingers flexed. The legs are extended and adducted, with the feet plantar flexed.
C.   Atypical hyperreflexia refers to exaggerated reflexes, not a specific posture.

D.   Decerebrate posturing is characterized by the arms extended and pronated, with the wrists and fingers flexed. The legs are stiffly extended with plantar flexion.

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Correct Answer is B

Explanation

A. Pupils round, 2mm and constricting to light is a normal pupil response.
B. Decreasing level of consciousness is a critical sign of deteriorating neurological status and requires immediate medical intervention.
C. Temporal headache is a common symptom after head injury but it is not as urgent as a decreasing level of consciousness.
D. Glasgow coma score of 13 indicates a mild to moderate head injury, but it's a static measurement. A decreasing level of consciousness would indicate worsening condition.

A. Abnormally prominent U wave B. Inverted P wave C. Elevated ST segment D. Wide QRS

Correct Answer is A

Explanation

A. Abnormally prominent U wave is a classic sign of hypokalemia. The U wave is normally small and often hidden by the T wave. When it becomes prominent, it's a strong indicator of low potassium levels.
B. Inverted P wave is more indicative of atrial abnormalities, such as atrial fibrillation.
C. Elevated ST segment is often associated with myocardial ischemia or injury.
D. Wide QRS is more characteristic of conduction disturbances like bundle branch blocks.

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A nurse is doing rounds and notes a patient in the following position: How would the nurse document this finding?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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