In the Neuro ICU, a comatose patient has this posture in bed: Upper arms are flexed tight to the sides with elbows, wrists, and fingers flexed. The legs are extended and internally rotated. The nurse interprets this posture as:

Decorticate Rigidity

Flaccid

Decerebrate Rigidity

Hemiplegia

Answer and Explanation

The Correct Answer is A

A.   Decorticate rigidity is characterized by flexion of the arms and extension of the legs. In this posture, the upper arms are flexed and held tightly to the sides, with the elbows, wrists, and fingers also flexed. The legs are extended and internally rotated.
B.   Flaccid posture, or flaccidity, is characterized by a complete lack of muscle tone, which leads to a limp and lifeless appearance. There is no resistance to passive movement, and the muscles are weak or paralyzed.

C.   Decerebrate rigidity is characterized by extension of both the arms and the legs. In this posture, the arms are extended at the sides with the wrists and fingers flexed, and the legs are extended and internally rotated. This type of rigidity indicates damage to the brainstem below the red nucleus.
D.   Hemiplegia refers to paralysis of one side of the body, which can result from brain injury or stroke affecting one hemisphere of the brain. The affected side will have limited or no movement and muscle tone.

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Correct Answer is B

Explanation

A. Blurred vision is generally associated with visual system issues, which involve the occipital lobe or the visual pathways rather than the frontal lobe. Broca’s area, located in the frontal lobe, is involved in speech production and not in vision processing.
B. Difficulty speaking is a key symptom associated with damage to Broca’s area, which is located in the frontal lobe and responsible for speech production. A contusion in this area can lead to expressive aphasia, where the individual has trouble forming grammatically correct sentences and articulating words, while comprehension remains relatively intact.
C. Loss of tactile sensation would generally be associated with damage to the parietal lobe, where the primary somatosensory cortex is located. The parietal lobe processes sensory information such as touch, temperature, and pain. Since Broca’s area is located in the frontal lobe and primarily deals with language production, loss of tactile sensation is not typically expected from a frontal lobe contusion affecting Broca's area.
D. Inability to hear high-pitched sounds relates to issues with the auditory pathways or structures involved in hearing, such as the temporal lobe or the auditory cortex, not the frontal lobe. The frontal lobe and Broca’s area do not directly control auditory perception.

A. Assess dilatation of pupils with direct light. B. Ask the client to differentiate between sharp and dull sensations on the client's face. C. Palpates temporal and masseter muscles while client clenches teeth. D. Have the client smile, frown, and wrinkle the forehead.

Correct Answer is C

Explanation

A. This test assesses the function of the oculomotor nerve (CN III), not the trigeminal nerve. The oculomotor nerve controls the constriction and dilation of the pupils, as well as some eye movements. Therefore, this choice is not appropriate for assessing the trigeminal nerve.
B. This test assesses the sensory function of the trigeminal nerve (CN V). The trigeminal nerve provides sensation to the face, and testing the ability to differentiate between sharp and dull sensations evaluates

the sensory component of this nerve. However, this test does not assess the motor function of the trigeminal nerve.
C. This test evaluates the motor function of the trigeminal nerve. The trigeminal nerve controls the muscles involved in chewing, including the temporal and masseter muscles. By palpating these muscles while the client clenches their teeth, the nurse assesses the strength and function of these muscles, which are innervated by the trigeminal nerve. This is a direct test of motor function for CN V.
D. This test assesses the function of the facial nerve (CN VII), which controls the muscles of facial expression. It is not relevant for assessing the trigeminal nerve, which is involved in both sensory functions of the face and motor functions related to chewing.

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In the Neuro ICU, a comatose patient has this posture in bed: Upper arms are flexed tight to the sides with elbows, wrists, and fingers flexed. The legs are extended and internally rotated. The nurse interprets this posture as:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following would the nurse most likely expect to find when assessing a client diagnosed with a frontal lobe contusion (in the Broca's Area) following a motor vehicle accident?

Correct Answer is B

Explanation

Which of the following tests would be most appropriate for the nurse to use when assessing motor function of the trigeminal nerve?

Correct Answer is C

Explanation

A client opens the eyes and answers questions however falls back asleep within seconds. How should the nurse document this assessment finding?

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