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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E","F"]
Explanation
A. "I will look up at the ceiling when I swallow.". The recommended position for swallowing is typically sitting upright with the chin slightly tucked.
B. "I will have to stop watching television while I eat." This indicates an understanding of the importance of focusing on eating and avoiding distractions.
C. "My food will have to be the consistency of pudding." This indicates understanding of the Level 3 dysphagia diet, which requires foods to be moist and easily swallowed.
D. "I can have cream soups on this diet." While cream soups might seem like a good option, they can be too thick for a Level 3 dysphagia diet. The consistency should be more like a thin purée.
E. "I shouldn't drink liquids while I have food in my mouth." This demonstrates understanding of the importance of avoiding choking hazards.
F. "I won't be able to eat nuts anymore." This indicates understanding of the restrictions on hard, crunchy foods on a Level 3 dysphagia diet.
Correct Answer is B
Explanation
A. The primary purpose of a halo fixation device is to immobilize the cervical spine to prevent further injury and promote healing.
B. The halo device provides rigid immobilization of the cervical spine.
C. This is incorrect and dangerous. The screws in the halo device should only be tightened by a healthcare professional.
D. Applying talcum powder under the halo vest can actually increase the risk of skin breakdown. The area should be kept clean and dry.
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