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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Verapamil, as a calcium channel blocker, can cause vasodilation (widening of blood vessels), which can lead to a decrease in blood pressure. Monitoring for hypotension is crucial when administering verapamil, especially via IV bolus, as it can rapidly lower blood pressure and potentially lead to symptoms such as dizziness, lightheadedness, or fainting.
B. Muscle pain is not a common or expected adverse effect of verapamil. While some medications might cause muscle-related symptoms, verapamil is more commonly associated with cardiovascular effects, such as hypotension and bradycardia, rather than muscle pain.
C. Ototoxicity is not a known adverse effect of verapamil. Ototoxicity is more commonly associated with other classes of drugs, such as certain antibiotics (e.g., aminoglycosides) or diuretics. Verapamil primarily affects the cardiovascular system, so ototoxicity is not a concern with this medication.
D. Hyperthermia is not a common adverse effect of verapamil. Verapamil does not typically affect body temperature regulation. Conditions associated with hyperthermia are more likely related to infections, overheating, or certain other medications, but not verapamil.
Correct Answer is B
Explanation
A. A high CVP, not a low CVP, is typically associated with fluid overload.
B. A low CVP indicates decreased fluid volume, which is characteristic of hypovolemia. This is particularly relevant to a patient with multiple traumas who may have significant blood loss.
C. While left ventricular failure can contribute to hemodynamic instability, it's not directly correlated with a low CVP.
D. This would affect the oxygenation status of the blood, rather than the overall blood volume and CVP.
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