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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. This client has no respirations and delayed capillary refill, suggesting a critical lack of oxygenation. However, the lack of respirations with no success in repositioning the airway indicates that this client may be beyond resuscitation. The priority would be to address clients who are still viable for treatment.
B. This client is at risk for respiratory distress due to the sucking chest wound and requires immediate attention. The wound could lead to a pneumothorax, which compromises oxygenation. The respirations of 38/min indicate distress, but the capillary refill of <2 seconds suggests better perfusion making this client a priority for care.
C. While this client requires treatment for the dislocated shoulder, their vital signs (normal respiratory rate and good capillary refill) indicate that this client is stable. This makes them a lower priority than the unconscious client with the sucking chest wound.
D. This client is experiencing shortness of breath and has a respiratory rate of 24/min, but their capillary refill is normal. Although this client needs further assessment, they are stable compared to the unconscious client with the sucking chest wound.
Correct Answer is A
Explanation
A. An initial loss of consciousness followed by a coherent period and a subsequent loss of consciousness: An epidural hematoma typically presents with a brief loss of consciousness, followed by a lucid period, then a second loss of consciousness. This pattern is a hallmark sign due to rapid pressure buildup from the blood.
B. Narrowing pulse pressure with tachycardia: Narrowing pulse pressure and tachycardia are not associated with an epidural hematoma. More commonly, widening pulse pressure and bradycardia (Cushing’s triad) are seen in severe cases of increased intracranial pressure.
C. Drainage of clear fluid from the ears and nose: Drainage of clear fluid from the ears and nose may suggest CSF leakage, typically due to a skull fracture. This is not specific to an epidural hematoma, which primarily involves bleeding between the dura and skull.
D. Extensive swelling under the eyes: "Raccoon eyes" can be seen with basal skull fractures, but it is not specific to epidural hematomas. The hallmark manifestation is the consciousness pattern described in option A.
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