A nurse is doing rounds and notes a patient in the following position: How would the nurse document this finding?

Spinal cord degeneration

Decorticate posturing

Atypical hyperreflexia

Decerebrate posturing

Answer and Explanation

The Correct Answer is D

A.   Spinal cord degeneration is a general term for the deterioration of the spinal cord and doesn't specifically describe the patient's posture.
B.   Decorticate posturing is characterized by the arms flexed and adducted, with the wrists and fingers flexed. The legs are extended and adducted, with the feet plantar flexed.
C.   Atypical hyperreflexia refers to exaggerated reflexes, not a specific posture.

D.   Decerebrate posturing is characterized by the arms extended and pronated, with the wrists and fingers flexed. The legs are stiffly extended with plantar flexion.

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Correct Answer is D

Explanation

A. Widening pulse pressure is typically associated with increased cardiac output, which is opposite to what happens in hypovolemic shock.
B. Pulse oximetry 96% is a normal oxygen saturation level and does not indicate shock.
C. Increased deep tendon reflexes is not a typical finding in hypovolemic shock.
D. Increased heart rate is a classic compensatory mechanism in response to decreased blood volume. The body tries to maintain blood pressure by increasing heart rate.

A. Amiodarone administration B. Epinephrine administration C. Defibrillation D. Airway management

Correct Answer is C

Explanation

A. amiodarone is a medication used to treat ventricular fibrillation administered after defibrillation.
B. Epinephrine is also used in cardiac arrest, but it is administered after unsuccessful defibrillation attempts.
C. Defibrillation is the immediate life-saving intervention for ventricular fibrillation. It delivers a high- energy shock to the heart to try to restore normal rhythm.
D. While important in cardiac arrest, it is not the immediate priority. Defibrillation takes precedence.

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A nurse is doing rounds and notes a patient in the following position: How would the nurse document this finding?

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Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the findings as an indication of hypovolemic shock?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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