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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Tachycardia is a classic sign of the compensatory stage of shock. The body attempts to increase cardiac output by increasing heart rate to maintain blood pressure.
B. Hypokalemia is more likely to occur in the later stages of shock, as it's associated with tissue breakdown and renal dysfunction.
C. Mottled skin is a sign of the progressive stage of shock, indicating poor peripheral perfusion.
D. Blood pressure 115/68 mmHg: While this might be considered within normal range, it's important to consider the baseline blood pressure of the patient. In the compensatory stage, blood pressure may be maintained, but there are other compensatory mechanisms in place (like increased heart rate) to do so.
Correct Answer is C
Explanation
A. Restraining the child's arms during a seizure is not recommended. Trying to hold or restrain a child’s movements can lead to injury for both the child and the caregiver. During a seizure, it is more important to ensure the child is in a safe environment and avoid any actions that might exacerbate the situation or cause harm.
B. Using a padded tongue blade is an outdated practice and is not recommended. This method was once thought to prevent the child from biting their tongue or injuring their mouth, but it can actually lead to broken teeth, injuries to the mouth, or cause airway obstruction. Instead, focusing on ensuring the child's safety and protecting their airway is more appropriate.
C. Positioning the child laterally (on their side) is an appropriate and recommended action during a seizure. This position helps keep the airway open and allows any fluids, such as saliva, to drain out of the mouth, which helps prevent aspiration and choking. This position is especially important if the child is at risk for vomiting or if the seizure lasts for a prolonged period.
D. Attempting to stop the seizure is not possible and is not recommended. Seizures typically resolve on their own, and trying to intervene actively can cause harm. Instead, focus on protecting the child from injury, monitoring the duration of the seizure, and providing support once the seizure is over.
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