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 A

Explanation

Choice A reason: Eyes are deviated to the right is an assessment finding that indicates increased intracranial pressure and possible herniation of the brain. It is a sign of cranial nerve III palsy, which affects the movement of the eye and the size of the pupil. It is a medical emergency that requires immediate intervention.

Choice B reason: Amnesia to the cause of the trauma is an assessment finding that indicates memory loss and possible concussion. It is a sign of damage to the temporal lobe, which is involved in memory formation and retrieval. It is not a medical emergency, but it requires further evaluation and monitoring.

Choice C reason: Complaint of mild headache is an assessment finding that indicates pain and discomfort. It is a common symptom of traumatic brain injury, but it is not specific or severe. It can be managed with analgesics and rest.

Choice D reason: Pupils constrict from 5 mm to 2 mm with direct light stimulus is an assessment finding that indicates normal pupillary response. It is a sign of intact cranial nerve II and III function, which control the vision and the pupil size. It is not a cause for concern or notification.

A. After the age of 60, the plasma volume increases and there is a decreased ability to fight infections. B. Healthy bone marrow function decreases with aging, which lowers the immune response to infection. C. older adults have an overactive antibody response to vaccines. D. An older person's blood is more prone to clotting, so infection-fighting cells cannot reach the source of infection quickly.

Correct Answer is B

Explanation

Choice A reason: This is incorrect. After the age of 60, the plasma volume decreases and there is a decreased ability to fight infections. The decrease in plasma volume reduces the blood flow and oxygen delivery to the tissues, which impairs the immune function.

Choice B reason: This is correct. Healthy bone marrow function decreases with aging, which lowers the immune response to infection. The bone marrow produces fewer white blood cells, which are essential for fighting infections. The older adult also has a reduced response to vaccines, which makes them more susceptible to infections.

Choice C reason: This is incorrect. Older adults have an underactive antibody response to vaccines. This means that they do not produce enough antibodies to protect themselves from the pathogens that the vaccine is supposed to prevent.

Choice D reason: This is incorrect. An older person's blood is more prone to clotting, but this does not affect the infection-fighting cells. The infection-fighting cells can still travel through the blood vessels and reach the source of infection. However, the increased risk of clotting can lead to other complications such as stroke or heart attack.

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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

The nurse is caring for a patient with a new traumatic brain injury and completes a neurologic assessment. The magnetic resonance imaging identifies an intracranial epidural hematoma. The nurse would immediately notify the provider of which assessment finding?

Correct Answer is A

Explanation

The daughter of an older adult asks the nurse why her father seems to have so many respiratory infections despite receiving the annual influenza vaccine. Select the nurse's best response.

Correct Answer is B

Explanation

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