Choice A rationale

Dysfunction in the cerebrum would likely result in different types of posturing, such as decorticate posturing, rather than decerebrate. The cerebrum is involved in controlling voluntary motor functions and damage here typically does not lead to decerebrate posturing.

Choice B rationale

Dysfunction in the brain stem results in decerebrate posturing, characterized by rigid extension of the arms and legs, downward pointing of the toes, and backward arching of the head. The brain stem is crucial for controlling basic life functions and its impairment leads to severe motor response issues.

Choice C rationale

Dysfunction in the spinal column typically does not lead to decerebrate posturing but may lead to different types of paralysis or movement issues depending on the location and severity of the damage.

Choice D rationale

Dysfunction in the motor cortex usually leads to abnormalities in voluntary movement, muscle tone, and coordination rather than decerebrate posturing which is more linked to brain stem issues.

Choice A rationale

Ataxic gait is characterized by uncoordinated movement, wide-based steps, and irregular distances between steps, often seen in cerebellar dysfunctions.

Choice B rationale

Dystrophic gait is associated with muscle weakness, often seen in muscular dystrophies, where there is difficulty in walking, a waddle-like walk, and frequent falls.

Choice C rationale

Steppage gait is associated with foot drop, where the individual lifts their knees higher than usual to avoid dragging their toes, often seen in peripheral neuropathies.

Choice D rationale

Helicopod gait involves the feet making a half-circle with each step and is often seen in individuals with certain neurologic disorders, such as hemiplegia or certain types of ataxia.

Choice A rationale

Documenting wound size includes measuring the length, width, and depth of the wound to track the healing process and plan appropriate interventions.

Choice B rationale

The wound bed should be assessed for tissue type (granulation, slough, or eschar), color, and the presence of any exudate or infection.

Choice C rationale

The periwound skin is the area around the wound which should be assessed for color, temperature, swelling, and signs of maceration or excoriation.

Choice D rationale

Pattern of eruption is more relevant to dermatological conditions such as rashes or lesions, and not a primary focus for documenting acute open wounds.

Choice A rationale

The dura mater is the outermost, tough, and fibrous layer of the meninges that provides protection to the brain and spinal cord.

Choice B rationale

Meninges collectively refer to the three layers of protective membranes (dura mater, arachnoid mater, and pia mater) that cover the brain and spinal cord.

Choice C rationale

The pia mater is the delicate innermost layer of the meninges that closely envelopes the brain and spinal cord, providing support and nourishment.

Choice D rationale

The arachnoid mater is the middle layer of the meninges that has a web-like appearance and provides cushioning for the brain and spinal cord.

Choice A rationale

The oculomotor nerve (cranial nerve III) is responsible for innervating the muscles that move the eye and lift the eyelid, as well as controlling pupil constriction and lens shape for focusing.

Choice B rationale

The vestibulocochlear nerve (cranial nerve VIII) is involved in hearing and balance, not in the movement of eye muscles or eyelids.

Choice C rationale

The facial nerve (cranial nerve VII) controls muscles of facial expression, taste sensations from the anterior two-thirds of the tongue, and functions in tear and saliva production.

Choice D rationale

The trigeminal nerve (cranial nerve V) is responsible for sensation in the face and motor functions such as biting and chewing, not for eye movements.

Choice A rationale

Stupor refers to a state of near-unconsciousness or insensibility, where the patient can be briefly aroused by vigorous or repeated stimuli.

Choice B rationale

Somnolence refers to a state of strong desire for sleep or sleeping for unusually long periods (drowsiness), but it is not as severe as stupor or coma.

Choice C rationale

Normal consciousness means the patient is awake, alert, and responsive to their environment with no neurological deficits.

Choice D rationale

A score of 6 on the Glasgow Coma Scale indicates deep coma, where the patient has minimal to no response to stimuli, indicating severe brain injury.

Choice A rationale

Normal posture involves relaxed and symmetrical positioning of the limbs without any abnormal flexion or extension.

Choice B rationale

Decorticate posturing is characterized by abnormal flexion of the upper extremities at the elbows and wrists, and extension of the lower extremities, often indicating damage to the corticospinal tract.

Choice C rationale

Decerebrate posturing involves extension and outward rotation of both the arms and legs, indicating damage to the brain stem, which is more severe than decorticate posturing.

Choice D rationale

Flaccid posture refers to a complete lack of muscle tone and resistance, often seen in severe cases of neurological damage or after a stroke. .

Choice A rationale

The nurse should check the equipment first when an ICP reading of 0 mm Hg is noted, as this may indicate equipment malfunction. An accurate ICP reading is critical for assessing and managing intracranial pressure to ensure the client's safety.

Choice B rationale

Continuing the assessment without checking the equipment may lead to incorrect conclusions based on a potentially faulty reading. It’s crucial to ensure the accuracy of the equipment before proceeding.

Choice C rationale

Documenting the reading as an effective treatment outcome without verifying its accuracy can be dangerous. An ICP reading of 0 mm Hg is unusual and warrants equipment verification.

Choice D rationale

Contacting the health care provider to review the care plan is premature until the equipment has been checked to rule out a false reading, ensuring the nurse provides accurate information.

Choice A rationale

Scoliosis refers to a lateral curvature of the spine, not an exaggeration of the lumbar spine curve, which is characterized by lordosis.

Choice B rationale

Lordosis is an exaggerated inward curve of the lumbar spine, often referred to as swayback. This condition is identified by the nurse as the client presents with an exaggerated lumbar curve.

Choice C rationale

Kyphosis describes an excessive outward curvature of the thoracic spine, resulting in a hunched back, not the lumbar spine.

Choice D rationale

Dowager's hump is a term commonly associated with kyphosis, characterized by a pronounced curvature of the upper back, not the lumbar region.

Choice A rationale

Tactile agnosia is the inability to recognize objects through touch, not vision. This condition affects the somatosensory cortex, impacting tactile processing.

Choice B rationale

Ataxia involves the loss of full control of bodily movements and coordination, not the inability to identify objects visually. It typically results from cerebellar dysfunction.

Choice C rationale

Visual agnosia is the inability to recognize familiar objects by sight despite having intact visual functioning. This condition often results from damage to the occipital or temporal lobes.

Choice D rationale

Positive Romberg sign indicates balance issues, typically seen when a client sways or falls when standing with eyes closed. It does not pertain to visual recognition deficits.