A nurse is collecting data from a client who has increased intracranial pressure and is informed by the charge nurse that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe?
Extension of the extremities
External rotation of the lower extremities
Pronation of the hands
Plantar flexion of the legs
The Correct Answer is D
a. Decorticate posturing is marked by the flexion of the arms, with the hands clenched into fists and the legs extended and internally rotated.
b. External rotation of the lower extremities is not a characteristic of decorticate posturing. In decorticate posture, legs are held out straight.
c. Pronation of the hands is characteristic of decerebrate posturing, where the arms are extended and pronated.
d. In decorticate posturing, the lower extremities typically exhibit plantar flexion. Additionally, the upper extremities show flexion of the arms, wrists, and fingers with adduction of the arms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nurse should reinforce to the client that Buck's traction promotes relief from muscle spasms. Buck's traction is a type of skin traction that is widely used for fractures of the femur and hip². It uses splints, bandages, and adhesive tapes to position a limb near the fracture and then applies pressure using weights and pulleys. One of the goals of Buck's traction is to lessen or eliminate muscular spasms.
a. Reduction of the fracture is not the primary purpose of Buck's traction.
b. Support for moving the extremity is not a primary outcome of Buck's traction.
c. Alignment of the pins is not applicable to Buck's traction as it does not involve inserting pins into the
bone.
Correct Answer is A,B,D,C
Explanation
The correct sequence of steps the nurse should follow when a client begins to experience a tonic-clonic seizure is:
- Remain with the client and call for help.
- Place the client in the lateral position.
- Check the client for injuries.
- Reorient and reassure the client.
The nurse should first remain with the client and call for help to ensure that additional assistance is on the way. Next, the nurse should place the client in the lateral position to help keep their airway open and prevent aspiration. After the seizure has ended, the nurse should check the client for injuries that may have occurred during the seizure. Finally, the nurse should reorient and reassure the client, who may be confused or disoriented after the seizure.
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