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 D

Explanation

A. Jerking contractions of the head and neck is more indicative of seizures or other neurological conditions.
B. Pinpoint pupils can be associated with various conditions, including opioid overdose or pontine hemorrhage, but it's not specifically related to Babinski's sign.
C. Pronation of the arms is a general assessment finding, not specifically indicative of a neurological issue.
D. Dorsiflexion of the great toe is the classic response for Babinski's sign. It is an abnormal reflex indicating upper motor neuron damage.

A. Elevate the head of the bed. B. Provide a brightly lit environment. C. Encourage a minimum intake of 2000 mL (67.6 oz) of clear fluids per day. D. Teach controlled coughing and deep breathing.

Correct Answer is A

Explanation

A. Elevating the head of the bed is a cornerstone of managing increased intracranial pressure (ICP). Elevating the head of the bed to 30 degrees promotes venous drainage from the brain, helping to reduce ICP.
B. A brightly lit environment can stimulate the patient and increase ICP. A calm, dark environment is preferred.
C. Fluid restriction, not encouragement, is often necessary to manage ICP. Excessive fluid can increase intracranial volume.
D. Controlled coughing and deep breathing are important for lung expansion but coughing and straining can increase ICP. Gentle breathing exercises are preferred.

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

Nursing Test Bank

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