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 A

Explanation

Choice A rationale

The nurse should check the equipment first when an ICP reading of 0 mm Hg is noted, as this may indicate equipment malfunction. An accurate ICP reading is critical for assessing and managing intracranial pressure to ensure the client's safety.

Choice B rationale

Continuing the assessment without checking the equipment may lead to incorrect conclusions based on a potentially faulty reading. It’s crucial to ensure the accuracy of the equipment before proceeding.

Choice C rationale

Documenting the reading as an effective treatment outcome without verifying its accuracy can be dangerous. An ICP reading of 0 mm Hg is unusual and warrants equipment verification.

Choice D rationale

Contacting the health care provider to review the care plan is premature until the equipment has been checked to rule out a false reading, ensuring the nurse provides accurate information.

A. Selective estrogen receptor modulators. B. Calcitonin. C. Bisphosphonates. D. Anabolic agents.

Correct Answer is C

Explanation

Choice A rationale

Selective estrogen receptor modulators (SERMs) are used for osteoporosis but are not typically the first-line treatment. They help to maintain bone density by mimicking estrogen's beneficial effects on bone.

Choice B rationale

Calcitonin is used to treat osteoporosis but is not considered a first-line medication. It works by inhibiting bone resorption, which helps to slow bone loss.

Choice C rationale

Bisphosphonates are the first-line medication for treating and preventing osteoporosis. They work by inhibiting bone resorption, which helps to maintain or increase bone density and reduce the risk of fractures.

Choice D rationale

Anabolic agents, such as parathyroid hormone analogs, are used for osteoporosis but are typically reserved for severe cases or when other treatments are not effective. They work by stimulating bone formation.

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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

When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first?

Correct Answer is A

Explanation

Which of the following is the first-line medication that would be used to treat and prevent osteoporosis?

Correct Answer is C

Explanation

The nurse documenting an acute open wound should include which characteristics? Select all that apply.

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