An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client?

Extension of the arms

External rotation of the lower extremities

Pronation of the hands

Plantar flexion of the legs

Answer and Explanation

The Correct Answer is D

- A) Extension of the arms is incorrect because decorticate posturing is characterized by flexion into the body, not extension away from it.
- B) External rotation of the lower extremities is not associated with decorticate posturing, which involves movements primarily of the upper extremities.
- C) Pronation of the hands is incorrect as decorticate posturing typically involves flexion of the arms, wrists, and fingers into the chest.
- D) Plantar flexion of the legs is correct because decorticate posturing includes internal rotation and flexion of the arms and wrists, with the legs extended and feet plantar flexed.

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Correct Answer is D

Explanation

A. The client can follow simple motor commands: A GCS score of 5 for the best motor response indicates that the client can localize pain but cannot follow simple motor commands. A score of 6 or higher is required to demonstrate following commands.

B. The client is unable to make vocal sound: A GCS score of 5 for the best verbal response indicates incomprehensible sounds or no verbal response. It does not specifically indicate the client's ability to vocalize or make sounds.

C. The client opens his eyes when spoken to: A GCS score of 3 for eye opening indicates no eye opening even to painful stimuli. It does not suggest that the client opens his eyes when spoken to.

D. The client is unconscious: A GCS score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response indicates severe neurological impairment, with the client being unresponsive to stimuli and unable to follow commands. Therefore, the appropriate conclusion is that the client is unconscious.

A. Intracranial pressure B. Respiratory status C. Temperature D. Serum electrolytes

Correct Answer is B

Explanation

A. Intracranial pressure: Monitoring intracranial pressure is important in clients with a history of subdural hematoma, but immediate assessment of respiratory status takes precedence in the immediate postoperative period to ensure adequate oxygenation and ventilation.

B. Respiratory status: Following evacuation of a subdural hematoma, the client may be at risk for respiratory compromise due to factors such as altered consciousness, impaired airway reflexes, or postoperative complications. Assessing respiratory rate, depth, oxygen saturation, and presence of respiratory distress is essential for early detection and intervention.

C. Temperature: Monitoring temperature is important for detecting signs of infection or systemic complications, but it is not the priority assessment immediately following evacuation of a subdural hematoma.

D. Serum electrolytes: While monitoring serum electrolytes is important for overall assessment and management of the client's condition, it is not the priority assessment in the immediate postoperative period following evacuation of a subdural hematoma.

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An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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