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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Increased ICP would be a concern when the MAP falls below 70 mm Hg because reduced blood pressure can lead to inadequate cerebral blood flow and worsen ICP.
B. Decreased cerebral blood flow (CBF) is also a concern with low MAP, but the priority is maintaining MAP at a sufficient level to ensure adequate perfusion.
C. Increased CPP is unlikely with a low MAP, as CPP is a product of MAP and ICP.
D. Normal ICP would be a good outcome; however, with a low MAP, the nurse should be concerned about insufficient cerebral perfusion and the risk of increased ICP.

A. Decreasing Glasgow Coma scores B. Swelling of the optic nerve C. Respiratory rate of 12/min D. Changes to pupil size and shape E. Blood pressure of 108/74 mm Hg

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

Explanation

A. Decreasing Glasgow Coma scores indicate a worsening neurological status and reduced consciousness.
B. Swelling of the optic nerve (papilledema) is a sign of increased ICP and indicates worsening conditions.
C. A respiratory rate of 12/min may be within normal range for some individuals but can also be a sign of impending respiratory depression in cases of severe ICP. However, it is not as immediately concerning as the other options in this case.
D. Changes in pupil size and shape are classic signs of worsening ICP. Unequal or nonreactive pupils are a key indicator.
E. Blood pressure of 108/74 mm Hg is not concerning unless it represents a significant drop from the baseline; other signs of worsening ICP are more critical in this case.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which outcome would concern the nurse when the patient's calculated mean arterial pressure (MAP) is below 70 mm Hg?

Correct Answer is B

Explanation

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

Explanation

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