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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Viral meningitis is typically self-limiting and patients usually recover fully without specific antiviral treatment.
B. Antibiotics are not effective against viral infections and are not indicated.
C. Viral meningitis is caused by viruses, not bacteria.
D. Viral meningitis is generally less severe than bacterial meningitis and rarely life-threatening.
Correct Answer is D
Explanation
A. The ventricles work simultaneously, not alternately, and both failing leads to compromised cardiac output.
B. Biventricular heart failure involves both the left and right ventricles, not just the left.
C. An ejection fraction above 50% is considered normal; in heart failure, especially biventricular, it is often reduced.
D. Biventricular heart failure means both ventricles are impaired, often resulting in a significantly reduced ejection fraction and poor cardiac function.
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