Which term would the nurse use to document a patient who is comatose from a head injury and display flexion of the arms, wrists, and fingers, as well as adduction of the upper extremities?
Decorticate posturing
Epileptic
Stroke
Decerebrate posturing
The Correct Answer is A
A. Decorticate posturing indicates severe brain injury, characterized by flexion of the arms and adduction of the upper extremities.
B. Epileptic is not a term used to describe posturing related to head injury.
C. Stroke does not describe posturing.
D. Decerebrate posturing is characterized by extension and pronation of the arms, not flexion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Put all used cosmetics in a plastic bag for one week to kill any bacteria before reusing: This is not a recommended intervention. Disinfecting or discarding the cosmetics would be better.
B. Disinfect contact lenses by soaking in a cleaning solution for 48 hrs: Bacterial conjunctivitis requires the patient to discard lenses for proper infection control.
C. Discard all opened or used contact lenses and lens care products: Discarding contaminated lenses and care products prevents reinfection.
D. Disinfect all lens care products with prescribed antibiotic drops for one-week post infection: This is not recommended as a general practice; lenses and solutions should be discarded instead.
Correct Answer is C
Explanation
A. A flat supine position is not recommended for patients with meningitis; they should be kept at a 30- degree angle to reduce ICP.
B. Restraining the patient is unnecessary unless there is an immediate risk of harm, and it can cause distress.
C. Reducing environmental stimuli helps minimize discomfort and risk of seizures, especially in meningitis, which causes hypersensitivity to light and sound.
D. Fluid intake should be monitored carefully. Excessive fluids may increase ICP in a patient with meningitis.
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