An acute care nurse receives 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?

Extension of the arms

External rotation of the lower extremities

Pronation of the hands

Plantar flexion of the legs

Answer and Explanation

The Correct Answer is D

- A) Extension of the arms is incorrect because decorticate posturing is characterized by flexion into the body, not extension away from it.
- B) External rotation of the lower extremities is not associated with decorticate posturing, which involves movements primarily of the upper extremities.
- C) Pronation of the hands is incorrect as decorticate posturing typically involves flexion of the arms, wrists, and fingers into the chest.
- D) Plantar flexion of the legs is correct because decorticate posturing includes internal rotation and flexion of the arms and wrists, with the legs extended and feet plantar flexed.

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Correct Answer is C

Explanation

A. "Engage in a vigorous exercise program." This statement may not be suitable for a client with multiple sclerosis experiencing symptoms such as diplopia, dysmetria, and sensory changes. While exercise is beneficial for managing MS symptoms, it should be tailored to the individual's abilities and symptoms.

B. "Plan to relax in a hot tub spa each day." Hot tubs can exacerbate symptoms of multiple sclerosis, particularly heat sensitivity. Therefore, this statement is not appropriate for this client.

C. "Implement a schedule to include periods of rest." Fatigue is a common symptom of multiple sclerosis, and incorporating regular periods of rest into the daily schedule can help manage fatigue and conserve energy.

D. "Wear an eye patch on the right eye at all times." While wearing an eye patch may help alleviate diplopia (double vision), it is not typically recommended for continuous use and should be used under the guidance of an ophthalmologist or healthcare provider.

A. “You might benefit from some psychological counseling." B. “The Department of Vocational Rehabilitation can help with work retraining." C. "Epilepsy usually can be well controlled with medications." D. “You will want to contact the Epilepsy Foundation for assistance."

Correct Answer is C

Explanation

A. “You might benefit from some psychological counseling." While psychological counseling may be helpful for coping with the emotional impact of epilepsy, it does not directly address the patient's concern about the possibility of having a seizure at work.

B. “The Department of Vocational Rehabilitation can help with work retraining." While
vocational rehabilitation services may be beneficial for individuals with disabilities, it may not directly address the patient's concern about continuing to work as a teacher.

C. "Epilepsy usually can be well controlled with medications." This response addresses the patient's concern by providing reassurance that epilepsy can often be effectively managed with medications. By effectively controlling seizures, the patient may be able to continue working without the fear of having a seizure at work.

D. “You will want to contact the Epilepsy Foundation for assistance." While the Epilepsy Foundation provides valuable resources and support for individuals with epilepsy, this response does not directly address the patient's concern about continuing to work.

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An acute care nurse receives 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is presenting discharge instructions to a client who has multiple sclerosis (MS). The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate?

Correct Answer is C

Explanation

A high school teacher who has been diagnosed with epilepsy after having a generalized tonic- clonic seizure tells the nurse, "I cannot teach anymore. It will be too upsetting if I have a seizure at work." How should the nurse respond to specifically address the patient's concern?

Correct Answer is C

Explanation

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An acute care nurse receives 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?

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