While providing care to a client with a head injury, the nurse notes that a client exhibits this posture (refer to figure). What should the nurse document that the patient is exhibiting?

Flaccidity

Rigidity in the upper extremities

Decerebrate posturing

Decorticate posturing

Answer and Explanation

The Correct Answer is D

A. Flaccidity: Flaccidity implies a complete lack of muscle tone and limpness. The patient in the image exhibits rigidity and specific posturing, which is the opposite of flaccidity.

B. Rigidity in the upper extremities: While there is rigidity, this option doesn't capture the specific pattern of posturing. The rigidity is part of a distinct decorticate pattern involving both upper and lower extremities in a specific way.

C. Decerebrate posturing: Decerebrate posturing is characterized by rigid extension of all four limbs, with pronation of the forearms. The image clearly shows flexion of the arms, which is the defining characteristic of decorticate posturing.

D. Decorticate posturing: The posture depicted in the image, with the arms flexed at the elbows and wrists and held close to the body, while the legs are extended, is the hallmark of decorticate posturing. This indicates severe brain injury above the level of the midbrain.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. A 30-year-old distraught mother holding her crying child: While the mother is distraught, her condition does not appear life-threatening. This client should be triaged to a lower priority compared to those with immediate medical needs.

B. A 65-year-old conscious male with a head laceration: A head laceration in a conscious client is concerning but not immediately life-threatening unless there are signs of more serious brain injury (e.g increased intracranial pressure). This client would be triaged as urgent, not emergent.

C. A 48-year-old with a simple fracture of the lower leg: A simple fracture is painful but does not typically threaten life or limb. This client is categorized as urgent but not emergent compared to others with more critical needs.

D. A 26-year-old male who has pale, cool, clammy skin: This client is showing signs of shock, which is a medical emergency. Pale, cool, and clammy skin suggests hypoperfusion, potentially due to hemorrhage, dehydration, or trauma. This client requires immediate intervention to restore circulation and prevent further deterioration.

A. Atrial Fibrillation (A-fib) B. Ventricular Fibrillation C. Ventricular Tachycardia D. Atrial Flutter (A-Flutter)

Correct Answer is B

Explanation

A. Atrial Fibrillation (A-fib): While Atrial Fibrillation is irregularly irregular and lacks discrete P waves, its QRS complexes are typically narrow and uniform, reflecting normal ventricular conduction. The QRS complexes in this strip are wide, bizarre, and highly irregular.

B. Ventricular Fibrillation: Ventricular fibrillation is characterized by rapid, chaotic electrical activity in the ventricles, resulting in no discernible P waves, QRS complexes, or T waves. The EKG appears as a disorganized, wavy line, indicating that the ventricles are merely quivering and not effectively pumping blood.

C. Ventricular Tachycardia: Ventricular tachycardia is typically a regular or slightly irregular rhythm with wide identifiable QRS complexes, and a rate usually between 100-250 bpm. While this rhythm is fast, it is completely chaotic and disorganized with no identifiable QRS complexes.

D. Atrial Flutter (A-Flutter): Atrial flutter is characterized by a "sawtooth" pattern of atrial activity (flutter waves) and typically a regular ventricular rhythm. This strip shows chaotic, disorganized ventricular activity, not organized flutter waves.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

While providing care to a client with a head injury, the nurse notes that a client exhibits this posture (refer to figure). What should the nurse document that the patient is exhibiting?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An emergency room nurse is triaging victims of a mass-casualty event. Which client should receive care first?

Correct Answer is D

Explanation

You note the cardiac electrical rhythm below (see 6-second EKG strip). Which of the following would BEST describe the client's rhythm?

Correct Answer is B

Explanation

A client admitted for difficulty breathing becomes worse. Which assessment findings indicate that the client has developed acute respiratory distress syndrome (ARDS)? Select all that apply

An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client?

A nurse enters a client's room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take?

A nurse is caring for a client who has the following arterial blood gas results: HCO3 18 mEq, PaCO2 28 mm Hg and pH 7.30. The nurse recognizes the client is experiencing which of the following acid-base imbalances?

A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. The client pulls out his endotracheal tube. Which of the following actions should the nurse take first?

A nurse is working with an emergency response team in caring for a group of people who may have been exposed to anthrax while doing farm work. Which of the following is the appropriate action for the nurse to take?

A nurse in the ICU is caring for a client who has poor cardiac output with heart failure and is receiving a Dopamine drip. The nurse should identify that which of the following findings indicates that the medication is effective?

A nurse on a medical-surgical unit is caring for a client who reports pain in the jaw, back, and shoulder, and shortness of breath and nausea. Which of the following actions should the nurse take?