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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Frequent swallowing is a common finding after a tonsillectomy due to postoperative throat discomfort and the sensation of having a foreign object in the throat (such as blood clots or mucus).

B. Reports of thirst may indicate dehydration, which can occur after surgery, especially if the child is not drinking enough fluids due to pain or discomfort. While dehydration can be a concern after a tonsillectomy, it is not a specific sign of hemorrhage.

C. Pain is common after a tonsillectomy and can be expected in the postoperative period. While increased pain may be present if hemorrhage occurs, it is not a specific sign of hemorrhage on its own.

D.Mouth breathing does not directly indicate bleeding and is more related to discomfort or difficulty breathing through the nose, especially if the child is experiencing throat pain. It is not a typical sign of hemorrhage.

A. Infants are in a supine or prone position most of the time. B. Sucking on a nipple creates middle ear pressure. C. The Eustachian tube is short, straight, and wide. D. Sucking on a nipple creates middle ear pressure.

Correct Answer is C

Explanation

C. The Eustachian tube in infants is shorter, straighter, and wider compared to adults. This anatomy makes it easier for bacteria or viruses from the nasopharynx to travel up the Eustachian tube and infect the middle ear, contributing to the increased susceptibility to otitis media.

A. Infants spend a significant amount of time lying down, whether in a supine (on their backs) or prone (on their stomachs) position. However, this does not increase the risk of otitis media

B. Sucking on a nipple does create pressure changes in the middle ear but it's not the primary reason infants are more susceptible to otitis media.

D. Sucking on a nipple does create pressure changes in the middle ear but it's not the primary reason infants are more susceptible to otitis media

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a child who is postoperative following a tonsillectomy for signs of hemorrhage. Which of the following findings is a sign of this postoperative complication?

Correct Answer is A

Explanation

A parent comments that her infant has had several ear infections in the past few months. Why are infants more susceptible to otitis media?

Correct Answer is C

Explanation

A nurse is preparing a 4-year-old child for discharge following a bilateral myringotomy with tympanostomy tube placement. The mother asks what to do if the tubes fall out. The nurse should give the parent which of the following instructions?

A nurse is collecting data from an infant who has otitis media. The nurse should expect which of the following findings?

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The nurse reviews the plan of care for a child with Reye's syndrome. The nurse plans to monitor for which priority complication of this syndrome?

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