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
Related Questions
Correct Answer is A
Explanation
Reduced tensile strength. A history of dislocations of the same joint may be due to an insufficient deposit of collagen during the healing process. Collagen is a protein that provides tensile strength to connective tissues such as tendons and ligaments. Reduced tensile strength may result in instability and dislocation of joints.
Option B: Loss of function is not a correct answer as it is a general term and can occur due to various reasons such as damage to muscles or nerves.
Option C: Lack of mobility is not a correct answer as it is similar to loss of function and does not explain the history of dislocations.
Option D: Allergic reaction is not a correct answer as it is not related to dislocations of joints.
Correct Answer is D
Explanation
sigmoid. A double-barrel colostomy involves surgically creating two separate stomas from the colon, with the proximal stoma discharging stool and the distal stoma discharging mucus. This type of colostomy is typically performed in the sigmoid colon, which is the S-shaped segment of the large intestine located just before the rectum.
Choice A, ascending, is not the correct answer because an ascending colostomy is created in the ascending colon, which is located on the right side of the abdomen.
Choice B, descending, is not the correct answer because a descending colostomy is created in the descending colon, which is located on the left side of the abdomen.
Choice C, transverse, is not the correct answer because a transverse colostomy is created in the transverse colon, which is located across the upper abdomen.
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