A patient arrives at the emergency center with a severe head injury. During assessment, the nurse observes that the patient is unresponsive, adducts the arms tightly against the thorax, and plantar flexes the feet while internally rotating them. How would the nurse document this abnormal posture?

Opisthotonos

Flaccid quadriplegia

Decorticate rigidity

Decerebrate rigidity

Answer and Explanation

The Correct Answer is D

Choice A reason: Opisthotonos is a severe arching of the back with hyperextension of the neck and limbs due to intense muscle spasms, often linked to tetanus or severe meningitis. It does not involve the specific arm adduction and foot plantar flexion with internal rotation described. This posture is unrelated to the neurological damage indicated, as it reflects a different pathological mechanism.

Choice B reason: Flaccid quadriplegia involves complete loss of muscle tone and voluntary movement in all four limbs, typically from spinal cord injury or neuromuscular disorders. The patient’s rigid arm adduction and plantar flexion indicate active muscle contraction, not flaccidity, making this an incorrect descriptor for the observed posture.

Choice C reason: Decorticate rigidity features arm flexion, clenched fists, and extended legs, typically due to cerebral cortex or internal capsule damage above the brainstem. The patient’s arm adduction and foot plantar flexion with internal rotation do not match this pattern, as decorticate posture lacks the internal rotation component.

Choice D reason: Decerebrate rigidity is marked by arm adduction, extension, and internal rotation, with legs extended and feet plantar flexed, as observed. This results from severe brainstem injury below the midbrain, disrupting corticospinal and vestibulospinal tracts, leading to unopposed extensor activity, accurately describing the patient’s posture.

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Correct Answer is D

Explanation

Choice A reason: Measuring respirations during pulse assessment can lead to inaccurate counts, as patients may alter their breathing when aware of pulse measurement. Conscious awareness often causes irregular or controlled breathing, which does not reflect the true respiratory rate, making this an unreliable time.

Choice B reason: Auscultation involves listening to lung or heart sounds, which requires patient cooperation and often affects breathing patterns. Patients may consciously modify their respirations during this process, leading to inaccurate respiratory rate measurements, rendering this an unsuitable time for assessment.

Choice C reason: Interviewing involves patient interaction, which can influence breathing due to speech or emotional responses. This conscious activity often results in irregular or controlled breathing patterns, making it an unreliable time to accurately measure the patient’s natural respiratory rate.

Choice D reason: Measuring respirations when the patient is sleeping ensures an undisturbed, natural breathing pattern, as the patient is unaware of the assessment. This allows the nurse to count the respiratory rate accurately, reflecting the true resting state, making it the optimal time.

A. The eyes converge and the pupils constrict to focus on the light. B. The constriction of both pupils occurs in response to bright light. C. The eyes focus the image in the center of the macula for precise vision. D. The eyes are normally aligned when the light is in the same location on each eye.

Correct Answer is D

Explanation

Choice A reason: Convergence and pupil constriction are accommodation reflexes, not corneal light reflex, which tests alignment. Light reflection symmetry indicates eye alignment, so this incorrect for the reflex’s purpose.

Choice B reason: Pupil constriction is a pupillary reflex, not corneal light reflex. The corneal reflex involves light reflection on corneas, assessing alignment, not pupil response, so this is incorrect.

Choice C reason: Macular focus is related to visual acuity, not corneal reflex, light reflex, which checks eye alignment via light reflection. Symmetric reflection is key, so this incorrect for the reflex’s indication.

Choice D reason: A normal corneal reflex shows light reflecting in the same spot on both corneas, indicating proper eye alignment. This is the definition of the reflex, making it the correct choice for eye assessment.

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A patient arrives at the emergency center with a severe head injury. During assessment, the nurse observes that the patient is unresponsive, adducts the arms tightly against the thorax, and plantar flexes the feet while internally rotating them. How would the nurse document this abnormal posture?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is the best time for the nurse to measure a patient's respirations?

Correct Answer is D

Explanation

A patient has a normal corneal light reflex. The nurse recognizes that this reflex indicates which information about the eyes?

Correct Answer is D

Explanation

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