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.

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

Explanation

A. Bradypnea: Bradypnea, or slow breathing, is a late sign of increased ICP. As pressure rises, the brainstem becomes compressed, leading to respiratory irregularities such as bradypnea. This can indicate a severe increase in ICP and requires immediate attention.

B. Cushing's triad: Cushing's triad, which consists of hypertension, bradycardia, and irregular respirations is a classic late sign of increased ICP. It occurs due to pressure on the brainstem and is a sign of impending brain herniation, which is a medical emergency.

C. Hypertension: Hypertension can be seen in the early stages of ICP due to compensatory mechanisms aimed at maintaining cerebral perfusion. However, it is not typically a late sign. The late sign would be an abnormal change in blood pressure patterns, as seen in Cushing's triad.

D. Mental status changes slightly: Slight mental status changes are an early sign of increased ICP, not a late one. As ICP rises, more pronounced changes in consciousness and cognition occur, such as confusion, stupor, or coma, signaling a more advanced stage of ICP.

E. Slurred speech: Slurred speech can be an early or moderate sign of ICP, depending on the location and severity of the pressure. However, it is not considered a late sign. More significant neurological impairments occur as ICP continues to increase.

A. Increase in the heart rate from 88 to 90/min B. Increase in the temperature from 99.5 °F to 100 °F C. Decrease in the respiratory rate from 20 to 16/min. D. Decrease in the urinary output from 50 mL to 30 mL per hour

Correct Answer is D

Explanation

A. Increase in the heart rate from 88 to 90/min: A heart rate increase of 2/min is not significant to indicate hypovolemic shock. In the early stages of hypovolemic shock, a more pronounced increase in heart rate is expected as a compensatory mechanism for low blood volume.

B. Increase in the temperature from 99.5°F to 100°F: A slight increase in temperature is common postoperatively and is generally not indicative of hypovolemic shock. A more concerning sign would be a fever that is significantly elevated or a rapid temperature change in combination with other symptoms.

C. Decrease in the respiratory rate from 20 to 16/min: A decrease in respiratory rate is not typically a sign of hypovolemic shock. In shock, respiratory rate often increases as the body compensates for decreased oxygen perfusion.

D. Decrease in the urinary output from 50 mL to 30 mL per hour: As the body experiences decreased perfusion due to blood loss, the kidneys are less able to filter and excrete urine. A decrease in urinary output indicates poor renal perfusion, which is a sign of shock.

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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

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Explanation

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Correct Answer is D

Explanation

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