The nurse is assessing a brain-injured client response to nail bed pressure. The client demonstrates internal rotation, adduction, and flexion of the arms, the nurse should report the response as which finding

Decerebrate posturing

Decorticate posturing

Flexion withdrawal

Localization of pain

Answer and Explanation

The Correct Answer is B

A. Decerebrate posturing: This involves extension and outward rotation of the arms, which is not observed here.

B. Decorticate posturing: Internal rotation, adduction, and flexion of the arms are characteristic of decorticate posturing, indicating damage to the corticospinal tract.

C. Flexion withdrawal: This refers to pulling away from a painful stimulus and does not involve the described pattern of movement.

D. Localization of pain: This is an intentional movement toward the source of pain, which is not demonstrated in this scenario.

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Correct Answer is A

Explanation

A. Administer oxygen via nasal cannula: The client's symptoms of dyspnea, chest pain, syncope, and hypotension suggest a possible acute cardiovascular event, such as a myocardial infarction (MI) or pulmonary embolism (PE). Administering oxygen should be the priority to improve oxygenation and prevent hypoxia, which could exacerbate the client's symptoms and further compromise cardiac function.

B. Administer prescribed pain medications. Pain relief may be necessary, but stabilizing oxygen levels is the priority.

C. Administer NS IV fluid. Fluid administration may be helpful, but oxygenation is more critical in this situation to address the potential underlying respiratory or cardiac issue.

D. Ask the provider for a dopamine prescription. While dopamine may be used in cases of shock, the immediate action should be to ensure the client is adequately oxygenated.

A. Troponin B. Alkaline phosphatase C. Creatine kinase D. Myoglobin

Correct Answer is A

Explanation

A. Troponin: Troponin is the most specific and reliable biomarker for myocardial injury. Levels rise within 3-6 hours and remain elevated for days, providing diagnostic and prognostic information.

B. Alkaline phosphatase: This is related to liver and bone disorders, not cardiac events.

C. Creatine kinase (CK): While CK-MB is specific to cardiac tissue, it is less specific and remains elevated for a shorter period compared to troponin.

D. Myoglobin: Myoglobin is an early but nonspecific marker of muscle damage and is not as reliable for diagnosing myocardial injury.

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The nurse is assessing a brain-injured client response to nail bed pressure. The client demonstrates internal rotation, adduction, and flexion of the arms, the nurse should report the response as which finding

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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