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 ["B","D"]

Explanation

A. Slurred speech is often an early sign of increased ICP due to focal brain injury affecting speech areas.
B. Bradycardia is a late sign of increased ICP and is part of Cushing's triad, which includes bradycardia, irregular respirations, and widened pulse pressure
C. Hypotension is not typically associated with increased ICP; in fact, hypertension may occur as the body attempts to maintain cerebral perfusion.
D. Nonreactive dilated pupils are a late sign of increased ICP, indicating potential compression of the third cranial nerve due to brain herniation.
E. Confusion can be an early or late sign of increased ICP, but it is not specific enough to be considered a definitive late sign without other context.

A. Restlessness B. Amnesia C. Tachycardia D. Hypotension

Correct Answer is A

Explanation

A. Restlessness: Restlessness is a common early sign of increased intracranial pressure (ICP) in clients with traumatic brain injury. It can result from discomfort, confusion, or agitation due to pressure on the brain.

B. Amnesia: Amnesia, or memory loss, can occur with traumatic brain injury but is not specifically indicative of increased intracranial pressure.

C. Tachycardia: Tachycardia may occur in response to various factors such as pain, stress, or fever, but it is not a specific indicator of increased intracranial pressure.

D. Hypotension: Hypotension (low blood pressure) is not typically associated with increased intracranial pressure. In fact, hypertension (high blood pressure) may be a compensatory response to maintain cerebral perfusion pressure in the setting of elevated ICP.

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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 caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that apply.)

Correct Answer is ["B","D"]

Explanation

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?

Correct Answer is A

Explanation

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