An acute care nurse receives a shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client?
Arms flexed at the elbows, with the hands and wrists bent toward the chest
Grimacing in pain when the neck is flexed, causing the legs to bend at the knee
The nurse is unable to extend the leg when the hip is flexed without causing the patient to grimace in pain
Arms extended, rigidly held straight out with palms of the hands turned away from the body
The Correct Answer is A
A. Decorticate posturing is characterized by arms flexed at the elbows with wrists and fingers bent inward toward the chest, indicating damage to the cerebral hemispheres or corticospinal tract.
B. Grimacing and leg movement with neck flexion describe a positive Brudzinski’s sign, related to meningeal irritation, not posturing.
C. Inability to extend the leg with hip flexion causing pain describes a positive Kernig’s sign, also related to meningeal irritation.
D. Arms extended and rigid with palms turned outward describe decerebrate posturing, indicating more severe brainstem injury.
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Correct Answer is D
Explanation
A. Reporting bacterial meningitis is not optional; it is a reportable disease due to its public health significance.
B. It is necessary to report all cases of bacterial meningitis to monitor and control outbreaks.
C. All cases, regardless of severity, must be reported, not just severe cases.
D. Bacterial meningitis is a nationally notifiable disease, meaning cases must be reported to the Centers for Disease Control and Prevention (CDC) to help track and prevent spread.
Correct Answer is D
Explanation
A. Specific gravity changes relate to kidney function and hydration status, not directly to right-sided heart failure.
B. Heparin levels are related to anticoagulation therapy, not heart failure status.
C. BNP levels decrease when heart failure improves; decreased BNP is not expected in acute heart failure.
D. BNP is released in response to ventricular stretch and volume overload; it increases in acute heart failure as the heart struggles to manage fluid overload.
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