A client is experiencing decorticate posturing. Which assessment finding would the nurse expect to observe in this client?

Flexion and internal rotation of upper extremities

Flexion and external rotation of upper extremities

Extension and internal rotation of upper extremities

Extension and external rotation of upper extremities

Answer and Explanation

The Correct Answer is A

A.   This description accurately depicts decorticate posturing. The characteristic feature of decorticate posturing is the flexion of the upper extremities (arms) and the extension of the lower extremities (legs). The internal rotation of the legs is often observed in this posture. This pattern is seen in severe brain damage, particularly involving the corticospinal tract.
B.   External rotation of the arms is not characteristic of decorticate posturing. In decorticate posturing, the arms are flexed and positioned close to the body, with internal rotation being more typical. Therefore, this option does not accurately describe decorticate posturing.
C.   Extension of the arms is more characteristic of decerebrate posturing rather than decorticate posturing. Decerebrate posturing involves the extension of both the arms and legs. Internal rotation of the arms is not a typical feature of decerebrate posturing, so this choice does not describe decorticate posturing.
D.   Extension and external rotation of the arms describe decerebrate posturing rather than decorticate posturing. Decerebrate posturing is characterized by the extension of the arms and legs, not flexion. Therefore, this option does not describe decorticate posturing.

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Free Nursing Study Resources

Correct Answer is ["A","D","E"]

Explanation

A. Drooling
Drooling can be concerning due to impaired swallowing and risk of aspiration.
D. Hoarse voice
Hoarseness after swallowing can indicate aspiration, which is a serious complication for stroke patients due to difficulty swallowing.
E. Temperature at 1800
A temperature of 39.6°C (103.3°F) is significantly elevated and suggests a potential infection, which is a serious complication after a stroke

A. Provide a nonskid mat to alleviate plate movement. B. Encourage the use of the wide grip utensils. C. Remind the client to look for food on the left side of the tray. D. Encourage the client to use his right hand when feeding himself.

Correct Answer is C

Explanation

A. While this is a good safety measure for any client, it doesn't address the specific issue of homonymous hemianopsia.
B. This can be helpful for clients with motor difficulties but does not address the visual impairment.
C. Since the client has a right-sided stroke and homonymous hemianopsia, they will likely miss food on the left side of their tray. Reminding them to scan that area can help prevent them from missing food.
D. While this might seem logical, it doesn't address the underlying issue of the client's visual impairment.

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A client is experiencing decorticate posturing. Which assessment finding would the nurse expect to observe in this client?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","D","E"]

Explanation

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Correct Answer is C

Explanation

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