A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates:

Dysfunction in the cerebrum.

Dysfunction in the brain stem.

Dysfunction in the spinal column.

Dysfunction in the motor cortex.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Dysfunction in the cerebrum would likely result in different types of posturing, such as decorticate posturing, rather than decerebrate. The cerebrum is involved in controlling voluntary motor functions and damage here typically does not lead to decerebrate posturing.

Choice B rationale

Dysfunction in the brain stem results in decerebrate posturing, characterized by rigid extension of the arms and legs, downward pointing of the toes, and backward arching of the head. The brain stem is crucial for controlling basic life functions and its impairment leads to severe motor response issues.

Choice C rationale

Dysfunction in the spinal column typically does not lead to decerebrate posturing but may lead to different types of paralysis or movement issues depending on the location and severity of the damage.

Choice D rationale

Dysfunction in the motor cortex usually leads to abnormalities in voluntary movement, muscle tone, and coordination rather than decerebrate posturing which is more linked to brain stem issues.

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Correct Answer is D

Explanation

Choice A rationale

Ligaments connect bones and stabilize joints. Age-related changes in ligaments result in decreased elasticity, leading to joint stiffness but not directly causing loss of height.

Choice B rationale

Bones undergo resorption and may lose density with age, leading to osteoporosis. While this contributes to height loss, it is not typically associated with diminished range of motion or flexibility as primary symptoms.

Choice C rationale

Muscles lose mass and strength with aging, a condition known as sarcopenia. This affects flexibility and range of motion but does not lead directly to height loss.

Choice D rationale

Joints are affected by age-related changes such as cartilage wear and synovial fluid reduction, leading to stiffness, loss of flexibility, diminished range of motion, and height loss due to spinal disc compression and vertebral changes.

A. The CPP is within normal limits. B. The CPP is low. C. The CPP reading is inaccurate. D. The CPP is high.

Correct Answer is B

Explanation

Choice A rationale

A CPP within normal limits ranges from 60 to 80 mm Hg, so a value of 40 mm Hg is not within this range.

Choice B rationale

A CPP of 40 mm Hg is considered low and indicates inadequate cerebral blood flow, which can result in brain ischemia and damage.

Choice C rationale

The reading of 40 mm Hg is considered accurate, as it reflects the current CPP of the client.

Choice D rationale

A CPP of 40 mm Hg is not high but low, indicating compromised cerebral perfusion.

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A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is exhibiting diminished range of motion, loss of flexibility, stiffness, and loss of height. The history and physical findings are associated with age-related changes of which area?

Correct Answer is D

Explanation

A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. How should the nurse interpret the CPP value?

Correct Answer is B

Explanation

A client who has suffered a stroke is unable to maintain respiration and is intubated and placed on mechanical ventilator support. What portion of the brain is most likely responsible for the inability to breathe?

A nurse is performing a neurologic assessment on the client and notes a positive Romberg test. This test for balance is related to which of the following cranial nerves?

The nurse is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly?

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The nurse assesses two new wounds located on a client's right and left buttocks. Which intervention for wound management would the nurse employ? Select all that apply.

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