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 D

Explanation

A. Orientation to person, place, and time is not expected in meningitis as the infection typically causes altered mental status.
B. Bradycardia is not a typical finding in meningitis. Increased intracranial pressure may lead to tachycardia, not bradycardia.
C. Blurred vision can occur with increased ICP or certain infections, but it is not a primary symptom of meningitis.
D. Severe headache is a hallmark symptom of meningitis, due to inflammation of the meninges, causing pain and increased intracranial pressure.

A. BP 126/54 mm Hg, pulse 58 beats/min, respirations 10 breaths/min B. BP 112/56 mm Hg, pulse 98 beats/min, respirations 28 breaths/min C. BP 129/65 mm Hg, pulse 60 beats/min, respirations 20 breaths/min D. BP 172/54 mm Hg, pulse 58 beats/min, respirations 10 breaths/min

Correct Answer is D

Explanation

A. BP 126/54 mm Hg, pulse 58 beats/min, respirations 10 breaths/min - While the low pulse and respirations should be assessed, this blood pressure isn't as concerning.
B. BP 112/56 mm Hg, pulse 98 beats/min, respirations 28 breaths/min - These vital signs are within a safer range compared to the critical changes in D.
C. BP 129/65 mm Hg, pulse 60 beats/min, respirations 20 breaths/min - These are stable vital signs.
D. The BP of 172/54 mm Hg, combined with bradycardia (pulse of 58 beats/min) and hypoventilation (respirations of 10 breaths/min), is indicative of Cushing's triad, a late sign of increased intracranial pressure, which is an emergency requiring immediate attention.

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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

A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

When the patient's initial vital signs after a brain injury were a BP of 132/72 mm Hg, pulse 100 beats/min, respirations 24 breaths/min, which subsequent vital signs would the nurse report immediately to the health care provider?

Correct Answer is D

Explanation

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