The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing?
Adduction of the arms at the shoulders
Abnormal flexion of the upper extremities and extension and adduction of lower extremities
Flaccid paralysis of all extremities
Rigid extension and pronation of the arms and legs
The Correct Answer is D
D. This is the correct characteristic of decerebrate posturing. Decerebrate posturing is characterized by rigid extension and pronation (turning inward) of the arms and legs. It indicates severe neurological dysfunction and increased intracranial pressure, often involving damage to the brainstem.
A. This characteristic is not associated with decerebrate posturing. Adduction refers to movement toward the midline of the body, which is not typically observed in decerebrate posturing.
B. This description is not characteristic of decerebrate posturing. Decerebrate posturing involves extension, not flexion, of the upper extremities, along with extension and pronation (not adduction) of the lower extremities.
C. Flaccid paralysis refers to the absence of muscle tone and movement, which is not characteristic of decerebrate posturing. Decerebrate posturing involves increased muscle tone and abnormal, rigid extension of the arms and legs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
A. Corticosteroids help reduce airway inflammation during an asthma exacerbation, which can help improve breathing and reduce symptoms.
D. Bronchodilator medications, such as albuterol, help relax the muscles around the airways, making it easier to breathe during an asthma exacerbation. They are typically used as rescue medications to provide immediate relief of asthma symptoms.
B. Placing the client in a supine position (lying flat on their back) is not recommended during an asthma exacerbation. This position can make breathing more difficult for someone experiencing respiratory distress.
C. Vigorous physical activity can exacerbate asthma symptoms and trigger an asthma attack. During an asthma exacerbation, it's important to encourage the client to rest and avoid strenuous activities that could worsen their breathing difficulties.
E. Cold compresses are not recommended for asthma exacerbations. Warm, moist air may help loosen mucus and ease breathing, but cold compresses could potentially exacerbate symptoms or discomfort.
Correct Answer is D
Explanation
D. Suctioning equipment and oxygen are essential items to have at the bedside for seizure precautions. Seizures can sometimes be associated with airway compromise, excessive secretions, or respiratory distress. Having suctioning equipment readily available allows for prompt removal of oral or airway secretions if necessary. Oxygen may be needed to support oxygenation during or after a seizure, especially if there are concerns about respiratory depression or hypoxemia.
A. A tracheotomy set is not typically needed at the bedside for seizure precautions. Tracheotomy sets are used in emergency situations to establish a surgical airway if there is a severe airway obstruction or respiratory distress.
B. An emergency cart contains essential supplies and medications needed for emergency situations, including resuscitation equipment, medications, and supplies for managing various medical emergencies. However, the cart is not placed bedside.
C. A padded tongue blade is not typically needed at the bedside for seizure precautions. Tongue blades are sometimes used during airway management to help visualize and manipulate the tongue, but padded tongue blades are not routinely included in seizure precautions.
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