The nurse is caring for a client with a deteriorating neurological condition. The nurse is performing an assessment at the beginning of the shift and notes a falling blood pressure and heart rate. The client is lying flat with arms and legs that are extended, stiff, and rigid, and the feet are plantar flexed. What would be the correct documentation of this posturing?
Stuporous.
Decerebrate.
Decorticate.
Flaccidity.
The Correct Answer is B
Choice A is incorrect because stuporous is a state of reduced consciousness, and does not describe the posturing observed in the client.
Choice B is correct because decerebrate posturing is characterized by extension of the arms, wrists, and fingers, and extension and internal rotation of the legs, with plantar flexion of the feet.
Choice C is incorrect - Decorticate posturing is characterized by flexion of the arms, wrists, and fingers, extension, internal rotation, and adduction of the legs, with plantar flexion of the feet. This is caused by damage to the cerebral cortex and is indicative of a neurological problem.
Choice D is incorrect because flaccidity is a state of complete lack of muscle tone, and does not describe the posturing observed in the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is ["B","C","D","E"]
Explanation
"Temperature regulation," "Protection," "Sensory processing," and "Chemical synthesis." These are all functions of the skin that the nurse should expect students to identify during a group discussion about the skin's functions. Choice A, "Metabolism," is not a primary function of the skin, although the skin does play a role in the synthesis of vitamin D, which can impact metabolism.
Correct Answer is A
Explanation
"I am at lower risk for developing cervical warts." This is an incorrect statement because the Gardasil vaccine does not protect against genital warts caused by HPV types other than types 6 and 11. The vaccine protects against HPV types 16 and 18, which cause most cases of cervical cancer.
B: This option is incomplete and does not provide any information for the nurse to determine if further teaching is needed.
C: This statement is correct and indicates that the client understands the purpose of the Gardasil vaccine.
D: This statement is incorrect because the Gardasil vaccine does not prevent HPV infection from occurring.
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