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 D

Explanation

Choice A reason: Assessment of arms and legs movement is an important part of the neurological assessment, but it is not the critical focus of care for a patient with a spinal cord injury at the cervical 5 vertebra. This level of injury affects the phrenic nerve, which controls the diaphragm and breathing. The patient may have difficulty breathing or require mechanical ventilation.

Choice B reason: Evaluation of knee jerk reflex is not the critical focus of care for a patient with a spinal cord injury at the cervical 5 vertebra. The knee jerk reflex is controlled by the spinal cord segments L2-L4, which are below the level of injury. The patient may have normal or exaggerated reflexes, depending on the extent of the spinal cord damage.

Choice C reason: Measurement of vital signs is a routine part of the nursing care, but it is not the critical focus of care for a patient with a spinal cord injury at the cervical 5 vertebra. The patient may have abnormal vital signs due to the injury, such as low blood pressure, slow heart rate, or irregular temperature. However, these are not as life-threatening as respiratory failure.

Choice D reason: Evaluation of respiratory status is the critical focus of care for a patient with a spinal cord injury at the cervical 5 vertebra. The patient is at high risk of respiratory compromise due to the impairment of the phrenic nerve and the diaphragm. The nurse should monitor the patient's oxygen saturation, respiratory rate, depth, and rhythm, and provide oxygen therapy or mechanical ventilation as needed. The nurse should also assess the patient for signs of respiratory infection, such as fever, cough, or sputum.

A. Flexion of the hip causes resistance to extension of the leg. B. Flexion of the neck causes flexion of the hips and knees. C. Flexion of the ankle causes upward fanning of the toes. D. Flexion of the neck causes pain and spasm in the leg muscles.

Correct Answer is B

Explanation

Choice A reason: Flexion of the hip causing resistance to extension of the leg is not a sign of meningitis. It is a sign of hip joint inflammation or injury.

Choice B reason: Flexion of the neck causing flexion of the hips and knees is a positive Brudzinski's sign. It indicates irritation of the meninges, the membranes that cover the brain and spinal cord.

Choice C reason: Flexion of the ankle causing upward fanning of the toes is not a sign of meningitis. It is a sign of an upper motor neuron lesion, such as a stroke or spinal cord injury.

Choice D reason: Flexion of the neck causing pain and spasm in the leg muscles is not a sign of meningitis. It is a sign of muscle strain or nerve compression.

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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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An emergency room nurse initiates care for a patient with a spinal cord injury at their cervical 5 vertebra after a motor vehicle accident. Select the nurse's critical focus of care:

Correct Answer is D

Explanation

The nurse assesses a patient who potentially may have meningitis. The patient demonstrates a positive Brudzinski's sign with which changes in position.

Correct Answer is B

Explanation

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