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
A. Heparin can be used to manage DIC but it's not a lifelong treatment and is part of a complex management plan.
B. DIC actually leads to a decreased platelet count due to excessive clotting.
C. DIC is an acquired condition, not a genetic one, and while vitamin K is involved in clotting, it's not the primary cause of DIC.
D. DIC is a complex disorder involving uncontrolled clotting and bleeding due to the depletion of clotting factors, including fibrinogen.
Correct Answer is B
Explanation
A. This is a late sign of shock. It occurs when the body's compensatory mechanisms fail to maintain blood pressure.
B. This is one of the earliest signs of shock. The body tries to compensate for decreased oxygen delivery by increasing the respiratory rate.
C. This is a very late sign of shock, indicating severe kidney damage due to decreased blood flow.
D. This is also a late sign of shock, occurring when the brain is deprived of oxygen.
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