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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Blood urea nitrogen assesses kidney function but is less directly related to digoxin toxicity risk.
B. Creatinine also reflects kidney function but is not the highest priority in this context.
C. Hemoglobin levels are not directly related to digoxin administration.
D. Potassium levels are critical to review because hypokalemia increases the risk of digoxin toxicity, and hyperkalemia can also affect the drug's efficacy. Monitoring potassium is essential before giving digoxin.
Correct Answer is D
Explanation
A. Furosemide typically causes hypokalemia (low potassium), not hyperkalemia.
B. There is no such thing as a potassium allergy; this statement is incorrect.
C. Furosemide does not increase potassium levels; it promotes potassium excretion.
D. Furosemide is a loop diuretic that increases the excretion of potassium in urine, so patients often require potassium supplementation to prevent hypokalemia.
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