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 C
Explanation
C. This is characteristic of Kernig's sign. Kernig's sign is elicited when the thigh is flexed at the hip and then attempts to extend the leg at the knee are met with resistance or pain due to inflammation of the meninges.
A. Petechial and purpuric rashes are associated with meningococcal meningitis, not specifically with Kernig's sign. These rashes result from bleeding into the skin and are a characteristic feature of meningococcal sepsis. However, they are not directly related to Kernig's sign.
B. This observation describes Brudzinski's sign, not Kernig's sign. Brudzinski's sign occurs when passive flexion of the neck causes involuntary flexion of the hips and knees due to meningeal irritation.
D. Muscle and joint pain can be symptoms of meningitis, but they are not specific to Kernig's sign. Kernig's sign specifically refers to resistance or pain experienced when attempting to extend the leg at the knee.
Correct Answer is A
Explanation
A. Rheumatic fever often develops as a complication of untreated or inadequately treated streptococcal throat infections, particularly group A Streptococcus. A history of a recent sore throat in a family member could suggest a streptococcal infection, which is a risk factor for developing rheumatic fever.
B. Chickenpox is caused by the varicella-zoster virus and is not directly related to rheumatic fever. While viral infections can trigger or exacerbate rheumatic fever in susceptible individuals, chickenpox itself is not a significant risk factor for rheumatic fever.
C. Fifth disease, also known as erythema infectiosum, is caused by parvovirus B19 and is not associated with rheumatic fever. Fifth disease primarily affects the skin, causing a characteristic rash, and is typically a mild illness in children.
D. Gastritis, inflammation of the stomach lining, is not directly related to rheumatic fever. While some gastrointestinal conditions may be associated with autoimmune disorders, gastritis itself is not a known risk factor for rheumatic fever.
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