When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, how should the nurse report the response?
Localization of pain
Decorticate posturing
Decerebrate posturing
Flexion withdrawal
The Correct Answer is B
Choice A rationale: Localization of pain refers to the ability of an individual to pinpoint the exact location of pain, which is different from the described response.
Choice B rationale: Decorticate posturing involves the arms flexing inward toward the body, which is consistent with the observed response to nail bed pressure.
Choice C rationale: Decerebrate posturing involves extension and outward rotation of the arms, which is different from the described response.
Choice D rationale: Flexion withdrawal typically involves pulling away from a painful stimulus, which differs from the specific response observed in the scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: Tachycardia and petechiae over the chest wall and buccal membranes are signs of fat embolism syndrome, another complication of fractures that occurs when fat globules enter the bloodstream and obstruct pulmonary vessels.
Choice B rationale: Positive Homan's sign with calf tenderness and warmth are signs of deep vein thrombosis, a condition that can occur after prolonged immobilization or surgery.
Choice C rationale: Acute cough, cyanosis, and decreased blood pressure are signs of pulmonary embolism, a life-threatening condition that occurs when a blood clot travels to the lungs and blocks blood flow.
Choice D rationale: These are signs of compartment syndrome, which is a serious complication of fractures that occurs when increased pressure within a closed space compromises blood flow and tissue perfusion. Compartment syndrome can lead to ischemia, necrosis, and nerve damage if not treated promptly.
Correct Answer is ["A","D","F"]
Explanation
Choice A rationale: Altered consciousness is a hallmark feature of delirium, where individuals may experience fluctuations in awareness.
Choice B rationale: Delirium typically has an acute onset rather than symptoms developing over months to years.
Choice C rationale: Delirium often has a fluctuating course, rather than a consistent progressive decline.
Choice D rationale: Delirium can result from various factors including fluid/electrolyte imbalances or infections.
Choice E rationale: While these conditions might contribute to cognitive impairments, they are not typically associated with delirium.
Choice F rationale: Delirium can affect judgment, but it's not a defining feature.
Choice G rationale: While memory impairments can be seen in delirium, they're often accompanied by altered consciousness and fluctuations in awareness.
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