A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates:
Dysfunction in the cerebrum.
Dysfunction in the brain stem.
Dysfunction in the spinal column.
Dysfunction in the motor cortex.
The Correct Answer is B
Choice A rationale
Dysfunction in the cerebrum would likely result in different types of posturing, such as decorticate posturing, rather than decerebrate. The cerebrum is involved in controlling voluntary motor functions and damage here typically does not lead to decerebrate posturing.
Choice B rationale
Dysfunction in the brain stem results in decerebrate posturing, characterized by rigid extension of the arms and legs, downward pointing of the toes, and backward arching of the head. The brain stem is crucial for controlling basic life functions and its impairment leads to severe motor response issues.
Choice C rationale
Dysfunction in the spinal column typically does not lead to decerebrate posturing but may lead to different types of paralysis or movement issues depending on the location and severity of the damage.
Choice D rationale
Dysfunction in the motor cortex usually leads to abnormalities in voluntary movement, muscle tone, and coordination rather than decerebrate posturing which is more linked to brain stem issues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Administering systemic antibiotics is essential to treat the underlying bacterial infection causing severe impetigo. This intervention helps reduce infection spread and promotes healing.
Choice B rationale
Placing mitts on the client's hands may prevent scratching, which can worsen impetigo, but it is not the primary treatment for the infection itself. Antibiotic therapy is more crucial.
Choice C rationale
Continuing antibiotics for 21 days is not a standard duration for impetigo treatment. The treatment duration typically ranges from 7 to 10 days, depending on the severity and response to treatment.
Choice D rationale
Topical antibiotics are used for mild cases of impetigo. For severe impetigo, systemic antibiotics are more appropriate and effective in managing the infection.
Correct Answer is C
Explanation
Choice A rationale
A pustule is an elevated, round lesion filled with pus, not serum. Pustules are commonly seen in acne or infections.
Choice B rationale
A macule is a flat, discolored area of the skin that is not elevated. Macules do not contain fluid and are often seen in conditions like freckles or flat moles.
Choice C rationale
A vesicle is an elevated, round lesion filled with clear serum. Vesicles can result from conditions such as chickenpox, herpes simplex, or dermatitis.
Choice D rationale
A cyst is an elevated, round lesion filled with semi-solid material or fluid. Cysts are typically deeper in the skin compared to vesicles.
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