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 D

Explanation

A. Perseveration refers to the repetition of a particular response or behavior despite the cessation of the stimulus that prompted it. This often occurs in individuals with neurological disorders, where they keep repeating the same word, phrase, or action.
B. Flight of ideas is a rapid flow of thoughts where the person moves quickly from one topic to another, often with tangential or disconnected ideas. It is commonly observed in conditions such as mania or hypomania.
C. Derailment, also known as loosening of associations, is a thought disorder where a person’s speech goes off-topic and seems disorganized. The connections between ideas are loose or fragmented, making the conversation difficult to follow.
D. Confabulation is a memory disturbance where a person creates false memories or fabricated details to fill in gaps in their memory. The individual does not intentionally deceive but genuinely believes their fabricated information is true.

A. Obturator sign B. Brudzinski sign C. Phalen sign D. Tinel sign

Correct Answer is B

Explanation

A. The obturator sign is used to assess for appendicitis, not meningitis. To perform this test, the patient’s right knee is flexed to 90 degrees, and the nurse rotates the hip internally and externally. Pain during this maneuver can indicate irritation of the obturator muscle, which is associated with inflammation of the appendix.

B. The Brudzinski sign is a clinical test used to assess meningeal irritation. When the patient’s neck is passively flexed while lying supine, a positive Brudzinski sign is indicated if the patient involuntarily flexes their knees and hips in response to neck pain. This sign is often seen in meningitis as a result of irritation of the meninges.
C. The Phalen sign is used to diagnose carpal tunnel syndrome. The patient flexes their wrists and holds the position for a period of time to see if symptoms of numbness or tingling appear in the fingers, which would indicate median nerve compression at the wrist. This sign is unrelated to meningitis.
D. The Tinel sign is also used to diagnose carpal tunnel syndrome and other peripheral nerve issues. It involves tapping on the nerve (such as the median nerve at the wrist) to see if it causes tingling or a “pins and needles” sensation along the nerve’s distribution. Like the Phalen sign, it is not related to meningitis.

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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:

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Naxlex Comprehensive Predictor Exams

While conducting an assessment the nurse suspects that a client is making up things in response to specific questions. What behavior is this client demonstrating?

Correct Answer is D

Explanation

A patient is diagnosed with Meningitis. During the physical examination in the supine position, the nurse flexed the patient's neck and the patient flexed his knees and hip while complaining of neck pain. This is known as:

Correct Answer is B

Explanation

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