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 D

Explanation

A. Ventricular aneurysm. Ventricular aneurysms are a complication that typically develops weeks or months after an MI.

B. Heart failure. While heart failure is a risk following an MI, it is more of a concern in the longer term after the acute phase.

C. Pulmonary embolism. Pulmonary embolism is not a direct complication of MI and is less common in the immediate post-MI period.

D. Dysrhythmia: Within the first 24 hours following a myocardial infarction, dysrhythmias, particularly ventricular arrhythmias, are common and can be life-threatening. This is the highest risk during the early period after MI.

A. Able to localize pain B. Is verbally responsive, but confused C. Moves arms as directed D. Opens eye to deep pain only

Correct Answer is D

Explanation

A. Able to localize pain: A score of 6 is too low for a client to localize pain, which would require higher motor function.

B. Is verbally responsive, but confused: Verbal responsiveness would require a higher score, as a GCS of 6 indicates severe impairment.

C. Moves arms as directed: Following commands is consistent with a higher GCS score.

D. Opens eyes to deep pain only: This response aligns with the minimal responsiveness expected for a GCS score of 6.

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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

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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