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. The client's blood pressure has decreased since the last visit. Decreased blood pressure is not a typical early sign of mitral valve stenosis.

B. The client's liver is enlarged and the abdomen is edematous. These are signs of more advanced heart failure, which can result from mitral valve stenosis but are not early indicators.

C. The client has jugular vein distention and 3+ pedal edema. Jugular vein distention and pedal edema are later signs of heart failure caused by mitral valve stenosis, not early signs.

D. The client complains of shortness of breath when walking. Shortness of breath on exertion is an early sign of mitral valve stenosis as the left atrium is unable to effectively pump blood into the left ventricle, leading to pulmonary congestion and difficulty breathing.

A. 0.9% normal saline IV at 100 mL/hr continuous B. Bumetanide (Bumex) 1 mg IV bolus every 12 hr C. Laboratory testing of serum potassium upon admission D. Morphine sulfate 2 mg IV bolus every 2 hr PRN pain E. Treats certain arrhythmias through the process of ablation

Correct Answer is A

Explanation

A. 0.9% normal saline IV at 100 mL/hr continuous: This order requires clarification. In acute heart failure, fluid management is crucial. A continuous IV infusion of normal saline could exacerbate fluid overload and worsen heart failure. Typically, IV fluids are given cautiously or restricted in heart failure cases.

B. Bumetanide (Bumex) 1 mg IV bolus every 12 hr: This is a loop diuretic, which is appropriate for managing fluid overload in heart failure.

C. Laboratory testing of serum potassium upon admission: This is appropriate, as diuretics like Bumex can lower potassium levels, so it is important to monitor electrolyte levels.

D. Morphine sulfate 2 mg IV bolus every 2 hr PRN pain: This is appropriate for pain management and to help with anxiety and breathing difficulties in acute heart failure.

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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

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Naxlex Comprehensive Predictor Exams

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