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 D
Explanation
Methylprednisolone is a crucial medication in managing anaphylaxis but it takes longer to act compared to epinephrine and is not the immediate first-line treatment.
B. Dobutamine is a vasopressor used to treat heart failure. However, it's not indicated in the initial management of anaphylaxis.
C. Furosemide is a diuretic used for conditions like heart failure and edema. It has no role in treating anaphylaxis.
D. Epinephrine is the first-line treatment for anaphylactic shock. It rapidly reverses the life-threatening effects of anaphylaxis by constricting blood vessels, relaxing airway muscles, and stimulating the heart.
Correct Answer is C
Explanation
A. Sedatives would further depress the respiratory muscles, worsening the myasthenic crisis.
B. Instruct the client to perform pursed lip breathing can be helpful for managing dyspnea in other conditions. However, it's not the priority in a myasthenic crisis where respiratory muscles are rapidly weakening.
C. As respiratory muscles weaken in a myasthenic crisis, the patient is at risk for respiratory failure. Preparing for mechanical ventilation is crucial.
D. A vasoconstrictor is used to treat shock, not a myasthenic crisis.
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