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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: In a conscious, alert, and oriented patient, the subjective report is the most reliable pain indicator, as pain is a subjective experience. The patient’s description of intensity, location, and quality directly reflects their perception, guided by neurological pain pathways, making this the gold standard.

Choice B reason: Vital signs like elevated heart rate or blood pressure may suggest pain but are nonspecific, as they can result from anxiety, exertion, or other conditions. They are less reliable than the patient’s verbal report, which directly conveys the pain experience.

Choice C reason: X-ray results may identify structural issues but cannot directly assess pain, a subjective sensation processed by the brain’s pain pathways. They are diagnostic, not experiential, making them unreliable for gauging pain in a conscious patient.

Choice D reason: Physical examination findings, like guarding or grimacing, are indirect pain indicators and less reliable than the patient’s subjective report. These signs may be absent or misleading in some patients, making the verbal description more accurate for pain assessment.

A. Submandibular and occipital B. Parotid and jugulodigastric C. Occipital and submental D. Parotid and submandibular

Correct Answer is D

Explanation

Choice A reason: The submandibular glands are palpable below the mandible, but occipital glands do not exist as salivary glands. The occipital region relates to lymph nodes or muscles, not salivary structures, making this an incorrect pair for palpation.

Choice B reason: The parotid glands are palpable near the ears, but jugulodigastric refers to lymph nodes, not salivary glands. This misidentification of anatomical structures makes this pair incorrect for assessing salivary gland palpation.

Choice C reason: Occipital and submental regions do not contain salivary glands. Submental lymph nodes exist, but neither these nor occipital structures are salivary glands, making this pair anatomically incorrect for the nurse’s palpation assessment.

Choice D reason: The parotid glands, located anterior to the ears, and submandibular glands, below the mandible, are the two pairs of salivary glands accessible for palpation. Their anatomical positions allow external assessment, making this the correct choice.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

The nurse is assessing a patient’s pain. Which would be the most reliable indicator of pain in a conscious, alert, and oriented patient?

Correct Answer is A

Explanation

When examining the face, the nurse is aware that which two pairs of salivary glands are accessible for palpation?

Correct Answer is D

Explanation

When the nurse asks an older patient to stand with feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. How should the nurse document this finding?

The nurse is reviewing the principles of pain. Which type of pain is due to an abnormal processing of the pain impulse through the peripheral or central nervous system?

Young women should have their first Pap smear examination at which age?

A patient is being assessed for range-of-joint movement. The nurse asks him to move his arm in toward the center of his body. What is this movement called?

A 62-year-old man states that his physician told him that he has an inguinal hernia. He asks the nurse to explain what a hernia is. How should the nurse respond?

A nurse examines a patient’s tympanic membranes with an otoscope. The nurse understands the normal tympanic membrane exhibits which normal characteristic?

What should the nurse do when assessing the carotid arteries of an older patient with cardiovascular disease?

A nurse is teaching a group of teen women. Which should the nurse discuss as the risk factor most associated with cervical cancer?