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: This can be a sign of increased ICP but is not typically considered a late sign. It is more often associated with early or moderate increases in ICP when the brain is starting to experience pressure but is not yet at a critical stage.
B. Bradycardia: This is a late sign of increased ICP and is part of Cushing's triad, which includes bradycardia, irregular respirations, and a widened pulse pressure. Bradycardia occurs as a compensatory mechanism to decrease the cerebral blood flow in response to increased ICP.
C. Hypotension: While changes in blood pressure can be associated with ICP, hypotension is not typically a late sign of increased ICP. In fact, hypertension with a widened pulse pressure would be more indicative of increased ICP as part of Cushing's triad.
D. Nonreactive dilated pupils: This is a late sign of increased ICP and indicates brain stem herniation or compression, which is a medical emergency. The pupils become fixed and dilated as the oculomotor nerve is compressed due to increased pressure.
E. Confusion: Confusion can be an early sign of increased ICP as it indicates changes in mental status. However, it is not specifically a late sign of increased ICP, as it can occur at various stages of pressure changes within the brain.

A. Slurred speech B. Bradycardia C. Hypotension D. Nonreactive dilated pupils E. Confusion

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.

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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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