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

Answer and Explanation

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.

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Correct Answer is A,B,C,D

Explanation

The order of the steps for the four-point alternate gait with crutches is as follows: move the right crutch about 10 to 15 cm (4 to 6 in), move the left foot forward, move the left crutch forward, and move the right foot forward. This gait patern provides maximum stability and support for the client by keeping three points of contact on the ground at all times.

A. Apply the elastic compression dressing tight enough so the toes and ankle become numb. B. Place moderate weight on the aﬀected leg when walking. C. Elevate the aﬀected ankle to the level of the heart. D. Apply heat during the first 24 hr.

Correct Answer is C

Explanation

The nurse should instruct the client to elevate the aﬀected ankle to the level of the heart. Elevation helps to reduce swelling and pain by promoting venous return and decreasing blood ﬂow to the injured area. This is an important part of the RICE (Rest, Ice, Compression, Elevation) method for treating sprains and strains.

a. The elastic compression dressing should not be applied so tight that it causes numbness in the toes and ankle.
b. The client should avoid placing weight on the aﬀected leg when walking until advised by a healthcare provider.
d. Heat should not be applied during the first 24 hours after a sprain as it can increase swelling and inﬂammation.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A,B,C,D

Explanation

A nurse is reinforcing teaching with a client who has an ankle sprain. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

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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?

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