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. Perform passive range of motion on each extremity. B. Record the client's intake and output. C. Suction saliva from the client's mouth. D. Monitor the client's electrolyte levels.

Correct Answer is C

Explanation

The highest priority nursing intervention for a client who is unconscious following a stroke is to suction saliva from the client's mouth. This can help prevent aspiration and maintain a patent airway, which is essential for the client's survival.

Performing passive range of motion on each extremity, recording the client's intake and output, and monitoring the client's electrolyte levels are also important nursing interventions for this client. However, these interventions are not as high of a priority as maintaining a patent airway.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A,B,C,D

Explanation

A nurse is caring for a client who is unconscious following a stroke. Which of the following nursing interventions is of highest priority?

Correct Answer is C

Explanation

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