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 B

Explanation

A. Remove clothing: While removing clothing may be necessary for a thorough assessment and treatment, maintaining cervical spine precaution takes precedence to prevent potential spinal cord injury in clients with a history of trauma, such as a fall from a significant height.

B. Maintain cervical spine precaution: Maintaining cervical spine precaution by stabilizing the cervical spine and immobilizing the neck is crucial to prevent further injury to the spinal cord in clients with a history of trauma until spinal injury is ruled out or managed.

C. Perform a mental status exam: While assessing the client's mental status is important for evaluating neurological function, it is not the first priority in a client with potential spinal cord injury following a fall.

D. Assess for facial lacerations: Assessing for facial lacerations is important for identifying and managing potential facial injuries, but it is not the first priority in the primary assessment of a client with a history of trauma and potential spinal cord injury.

A. “You might benefit from some psychological counseling." B. “The Department of Vocational Rehabilitation can help with work retraining." C. "Epilepsy usually can be well controlled with medications." D. “You will want to contact the Epilepsy Foundation for assistance."

Correct Answer is C

Explanation

A. “You might benefit from some psychological counseling." While psychological counseling may be helpful for coping with the emotional impact of epilepsy, it does not directly address the patient's concern about the possibility of having a seizure at work.

B. “The Department of Vocational Rehabilitation can help with work retraining." While
vocational rehabilitation services may be beneficial for individuals with disabilities, it may not directly address the patient's concern about continuing to work as a teacher.

C. "Epilepsy usually can be well controlled with medications." This response addresses the patient's concern by providing reassurance that epilepsy can often be effectively managed with medications. By effectively controlling seizures, the patient may be able to continue working without the fear of having a seizure at work.

D. “You will want to contact the Epilepsy Foundation for assistance." While the Epilepsy Foundation provides valuable resources and support for individuals with epilepsy, this response does not directly address the patient's concern about continuing to work.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse in the emergency department is caring for a client who has fallen 20 feet from a roof. While performing the primary assessment, what is the most important nursing intervention?

Correct Answer is B

Explanation

A high school teacher who has been diagnosed with epilepsy after having a generalized tonic- clonic seizure tells the nurse, "I cannot teach anymore. It will be too upsetting if I have a seizure at work." How should the nurse respond to specifically address the patient's concern?

Correct Answer is C

Explanation

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