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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["B","C","D","E"]

Explanation

"Impaired verbal communication," "Impaired swallowing," and "Self-care deficit." These are all potential nursing diagnoses for a client who has suffered a cerebral vascular accident. Pain may not be a priority nursing diagnosis in this situation.

A. Radiation therapy. B. Laser surgery. C. Cryosurgery. D. Radical excision.

Correct Answer is D

Explanation

Radical excision. Treatment of melanoma includes surgical excision of the tumor with a margin of normal tissue to decrease the risk of recurrence. Radical excision involves the removal of the tumor, adjacent tissue, and possibly lymph nodes.

Option A, radiation therapy, may be used as an adjunct therapy, but it is not the primary treatment.

Option B, laser surgery, may be used to remove superficial lesions, but not for melanoma.

Option C, cryosurgery, is used to remove benign lesions or precancerous cells, but not for melanoma.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

You have a client admitted to the unit having suffered a cerebral vascular accident. You are planning the plan of care for the client. What nursing diagnosis would be included in the client's plan of care? Select all that apply.

Correct Answer is ["B","C","D","E"]

Explanation

Treatment of melanoma includes which of the following?

Correct Answer is D

Explanation

During a pharmacology class, the students are told that some drugs need to be closely monitored. What aspect should the nurse closely monitor for in clients who have been administered salicylates, loop diuretics, quinidine, quinine, or aminoglycosides?

The nurse is performing an assessment of the thyroid gland. In order to decrease the risk that the nurse will stimulate the release of large amounts of thyroid hormone, what should the nurse be sure to do?

Which of the following interventions would be appropriate for a client who has undergone surgery for a disorder and has started shivering?

Which of the following interventions would be appropriate for a client who has undergone surgery for a liver disorder and has started shivering?

The nurse is caring for clients with spinal deformities. Which type of deformity would have the most significant consequences on the respiratory system?

A client in chronic renal failure becomes confused and complains of abdominal cramping, racing heart rate, and numbness of the extremities. The nurse relates these symptoms to which of the following lab values?

The nurse is providing client education on growth and development throughout the lifespan. When stating periods of most rapid bone growth, which period is the nurse most correct to state?

Which technique would be most beneficial for ambulation of a client who is visually impaired?