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 D

Explanation

D. Place resuscitation equipment at the child's bedside. This is because epiglottitis can lead to a life- threatening emergency requiring immediate intervention, and having resuscitation equipment readily available is essential for rapid response.

A. Establishing intravenous access may be necessary for administering fluids and medications but it is not the nurse's priority action when caring for a child with suspected epiglottitis.

B. Droplet precautions help reduce the risk of transmission of respiratory pathogens to others. However, the priority is to address the child's respiratory distress and potential airway compromise.

C. Providing blow-by humidified oxygen can be beneficial in managing the child's respiratory status. However, securing the airway takes precedence over other interventions, as indicated by the guidelines for managing epiglottitis.

A. Warm extremities B. Wheezing C. Nasal flaring D. Retraction of sternal muscles E. Oxygen saturation 95%

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

Explanation

B. Wheezing is a common symptom of asthma exacerbation and can indicate airway obstruction. Wheezing may worsen during an asthma attack, suggesting deterioration in respiratory status.

C. Nasal flaring is a sign of increased respiratory effort and can occur during respiratory distress. In a child with asthma, nasal flaring may indicate worsening airway obstruction and increased work of breathing, suggesting deterioration in respiratory status.

D. Retraction of sternal muscles, also known as intercostal retractions, occurs when the muscles between the ribs are drawn inward during inspiration, indicating increased effort to breathe. Intercostal retractions are a sign of respiratory distress and can occur in children with asthma during exacerbations, particularly when airway obstruction is severe.

A. Warm extremities are not typically indicative of deterioration in respiratory status in a child with asthma. In fact, warm extremities may suggest adequate peripheral perfusion.

E. An oxygen saturation of 95% is within the normal range for most children and may not necessarily indicate deterioration in respiratory status. However, oxygen saturation should be interpreted in conjunction with other clinical signs and symptoms.

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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 caring for a preschool-aged child who presents with manifestations of epiglottitis. Which of the following actions is the nurse's priority to perform?

Correct Answer is D

Explanation

A nurse is collecting data from a child who has asthma. Which of the following are indications of deterioration in the child's respiratory status? (Select All that Apply.)

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

Explanation

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