A patient with a severe head injury assumes a posture of flexed arms at the elbows and extended lower legs. The nurse recognizes this posturing as

decreasing intracranial pressure with decerebrate posturing.

increasing intracranial pressure with decorticate posturing.

decreasing intracranial pressure with decorticate posturing.

increasing intracranial pressure with decerebrate posturing.

Answer and Explanation

The Correct Answer is B

Choice A reason: Decreasing intracranial pressure with decerebrate posturing is not the correct answer. Decerebrate posturing is a sign of severe brain damage that involves the extension and outward rotation of the arms and legs, and the arching of the back. It is not associated with decreasing intracranial pressure, but rather with increased pressure or brainstem compression.

Choice B reason: Increasing intracranial pressure with decorticate posturing is the correct answer. Decorticate posturing is a sign of severe brain damage that involves the flexion of the arms at the elbows and the extension of the legs. It is associated with increased intracranial pressure or lesions in the cerebral hemispheres.

Choice C reason: Decreasing intracranial pressure with decorticate posturing is not the correct answer. Decorticate posturing is a sign of severe brain damage that involves the flexion of the arms at the elbows and the extension of the legs. It is not associated with decreasing intracranial pressure, but rather with increased pressure or lesions in the cerebral hemispheres.

Choice D reason: Increasing intracranial pressure with decerebrate posturing is not the correct answer. Decerebrate posturing is a sign of severe brain damage that involves the extension and outward rotation of the arms and legs, and the arching of the back. It is associated with increased intracranial pressure or brainstem compression, but it is not the posture described in the question.

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Correct Answer is B

Explanation

Choice A reason: This is incorrect. Anticoagulant therapy may be necessary to prevent pulmonary thrombosis in patients with ischemic stroke, which is caused by a blood clot blocking a blood vessel in the brain. However, in patients with hemorrhagic stroke, which is caused by a ruptured blood vessel in the brain, anticoagulant therapy can worsen the bleeding and increase the risk of complications.

Choice B reason: This is correct. Anticoagulant therapy is contraindicated because it will cause additional bleeding in patients with hemorrhagic stroke. Anticoagulants are drugs that prevent blood from clotting or dissolve existing clots. They can increase the size of the hematoma and the pressure on the brain tissue, leading to more damage and disability.

Choice C reason: This is incorrect. Anticoagulant therapy is not inadvisable because it may mask signs and symptoms of neurologic changes in the brain. Anticoagulants do not affect the neurological assessment or the diagnosis of stroke. They can, however, interfere with the treatment and recovery of hemorrhagic stroke.

Choice D reason: This is incorrect. Anticoagulant therapy will not be started if necessary to enhance cerebral circulation in patients with hemorrhagic stroke. Anticoagulants do not improve the blood flow to the brain, but rather prevent or dissolve clots that may obstruct it. In patients with hemorrhagic stroke, the pro

A. Patient should increase daily iron supplements. B. Signs and symptoms of infection. C. Our child will need to have blood transfusions. D. Swimming is a good activity for our child.

Correct Answer is A

Explanation

Choice A reason: Patient should increase daily iron supplements, is a statement that indicates a need for additional teaching. Iron supplements are not recommended for patients with beta-thalassemia, because they already have high levels of iron in their blood due to the frequent blood transfusions. Excess iron can cause damage to the liver, heart, and other organs. Therefore, the patient should avoid iron supplements and foods rich in iron, and take chelation therapy to remove the excess iron from the body.

Choice B reason: Signs and symptoms of infection, is a statement that does not indicate a need for additional teaching. Patients with beta-thalassemia are at risk of developing infections, due to the impaired immune system and the exposure to blood-borne pathogens. Therefore, the patient should be aware of the signs and symptoms of infection, such as fever, chills, sore throat, cough, or skin lesions, and seek medical attention promptly.

Choice C reason: Our child will need to have blood transfusions, is a statement that does not indicate a need for additional teaching. Blood transfusions are the main treatment for patients with beta-thalassemia, because they help to increase the level of hemoglobin and red blood cells, and prevent anemia and its complications. Therefore, the patient should receive regular blood transfusions, usually every two to four weeks, depending on the severity of the condition.

Choice D reason: Swimming is a good activity for our child, is a statement that does not indicate a need for additional teaching. Swimming is a good activity for patients with beta-thalassemia, because it helps to improve the cardiovascular fitness, muscle strength, and joint mobility, and reduce the stress and fatigue. Therefore, the patient should engage in moderate physical activities, such as swimming, walking, or cycling, as tolerated, and avoid strenuous or competitive sports that can cause injury or dehydration.

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A patient with a severe head injury assumes a posture of flexed arms at the elbows and extended lower legs. The nurse recognizes this posturing as

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Naxlex Comprehensive Predictor Exams

A family member of a patient diagnosed with a hemorrhagic stroke asks if the patient can receive anticoagulant therapy to improve their outcome. The nurse explains that anticoagulant therapy for the patient

Correct Answer is B

Explanation

When teaching the parents and patients newly diagnosed with beta-thalassemia, which statement made by the parents or patients indicates a need for additional teaching?

Correct Answer is A

Explanation

The nurse is preparing a teaching session about Guillain-Barre syndrome. Which statement should be included in the presentation?

A patient with acute myelogenous leukemia (AML) asks the nurse why their bones are making more white blood cells when they already have so many. The nurse clarifies that the large number of leukemic white cells they have:

The nurse is caring for a patient with a head injury after a fall from a ladder. The nurse must evaluate the patient for which signs and symptoms of increased intracranial pressure?

A nurse is caring for a client who begins to exhibit seizure activity while in bed. Which of the following actions should the nurse implement to care for the client?

The home health nurse visits a patient with multiple sclerosis who complains of severe fatigue. Select the nurse's best suggestion to help decrease their symptom of fatigue.

The nurse completes a focused assessment and history of a patient who is scheduled for magnetic resonance imaging (MRI). Which data shared by the patient would the nurse need to contact the provider?

Postoperative care for a patient having a craniotomy to relieve increased intracranial pressure, the nurse should implement which intervention?

The nurse completes a Romberg's test on a patient with neurologic changes. The nurse will notify the provider if they observe which response?