A nurse is caring for a client in the emergency department who has a preliminary diagnosis of a transient ischemic attack (TIA). Which of the following diagnostic testing should the nurse anticipate the provider to prescribe?

A. Extension of the extremities

Extension of the extremities is not consistent with decorticate posturing. Instead, it is more indicative of decerebrate posturing, where both the upper and lower extremities are typically extended.

B. Pronation of the hands

Pronation of the hands is not typically associated with decorticate posturing. In decorticate posturing, the hands are usually flexed with the wrists and fingers pointing towards the body.

C. Plantar flexion of the legs

Plantar flexion of the legs characteristic of decorticate posturing. Decorticate posturing mainly involves plantar flexion of the feet.

D. External rotation of the lower extremities

External rotation of the lower extremities is also not typically associated with decorticate posturing. In decorticate posturing, the lower extremities may exhibit extension or internal rotation, but external rotation is not a characteristic feature.

A. Adventitious breath sounds:

Adventitious breath sounds refer to abnormal lung sounds heard upon auscultation of the chest. These sounds include crackles (rales), wheezes, rhonchi, and pleural friction rubs. In the context of fluid volume excess, particularly in the acute phase of a cerebrovascular accident (CVA) or stroke, adventitious breath sounds such as crackles are indicative of pulmonary edema. Pulmonary edema occurs when there is an excessive accumulation of fluid in the lungs, impairing gas exchange and leading to symptoms such as shortness of breath and respiratory distress.

B. Weak pulse:

A weak pulse may suggest poor perfusion or decreased cardiac output rather than fluid volume excess. While decreased cardiac output can be a consequence of heart failure, which may be associated with fluid volume excess, a weak pulse is not a direct indicator of fluid overload. In the acute phase of a CVA, a weak pulse may prompt further assessment for other cardiovascular complications or neurogenic shock.

C. Hypotension:

Hypotension, or low blood pressure, is not typically associated with fluid volume excess. Instead, hypotension may indicate hypovolemia, shock, or other underlying cardiovascular conditions. While hypotension can occur secondary to severe heart failure or fluid overload in some cases, it is not a direct indicator of fluid volume excess in the acute phase of a CVA.

D. Poor skin turgor:

Poor skin turgor is a clinical finding associated with dehydration rather than fluid volume excess. In dehydration, the skin loses its elasticity and becomes less resilient when pinched. In contrast, fluid volume excess is characterized by edema, which may manifest as pitting or non-pitting edema, rather than poor skin turgor. However, in fluid volume excess, the skin may appear stretched or taut due to the accumulation of fluid in the interstitial spaces.