Exhibits

A nurse is providing discharge teaching. Which of the following client statements indicate an understanding of the teaching?
Client Statements

"I will look up at the ceiling when I swallow."

"I will have to stop watching television while I eat."

"My food will have to be the consistency of pudding."

"I can have cream soups on this diet."

"I shouldn't drink liquids while I have food in my mouth."

"I won't be able to eat nuts anymore."

Answer and Explanation

Correct Answer : B,C,E,F

A.   "I will look up at the ceiling when I swallow.". The recommended position for swallowing is typically sitting upright with the chin slightly tucked.
B.   "I will have to stop watching television while I eat." This indicates an understanding of the importance of focusing on eating and avoiding distractions.
C.   "My food will have to be the consistency of pudding." This indicates understanding of the Level 3 dysphagia diet, which requires foods to be moist and easily swallowed.
D.   "I can have cream soups on this diet." While cream soups might seem like a good option, they can be too thick for a Level 3 dysphagia diet. The consistency should be more like a thin purée.
E.   "I shouldn't drink liquids while I have food in my mouth." This demonstrates understanding of the importance of avoiding choking hazards.
F.   "I won't be able to eat nuts anymore." This indicates understanding of the restrictions on hard, crunchy foods on a Level 3 dysphagia diet.

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Correct Answer is B

Explanation

A. Pupils round, 2mm and constricting to light is a normal pupil response.
B. Decreasing level of consciousness is a critical sign of deteriorating neurological status and requires immediate medical intervention.
C. Temporal headache is a common symptom after head injury but it is not as urgent as a decreasing level of consciousness.
D. Glasgow coma score of 13 indicates a mild to moderate head injury, but it's a static measurement. A decreasing level of consciousness would indicate worsening condition.

A. Flexion and internal rotation of upper extremities B. Flexion and external rotation of upper extremities C. Extension and internal rotation of upper extremities D. Extension and external rotation of upper extremities

Correct Answer is A

Explanation

A. This description accurately depicts decorticate posturing. The characteristic feature of decorticate posturing is the flexion of the upper extremities (arms) and the extension of the lower extremities (legs). The internal rotation of the legs is often observed in this posture. This pattern is seen in severe brain damage, particularly involving the corticospinal tract.
B. External rotation of the arms is not characteristic of decorticate posturing. In decorticate posturing, the arms are flexed and positioned close to the body, with internal rotation being more typical. Therefore, this option does not accurately describe decorticate posturing.
C. Extension of the arms is more characteristic of decerebrate posturing rather than decorticate posturing. Decerebrate posturing involves the extension of both the arms and legs. Internal rotation of the arms is not a typical feature of decerebrate posturing, so this choice does not describe decorticate posturing.
D. Extension and external rotation of the arms describe decerebrate posturing rather than decorticate posturing. Decerebrate posturing is characterized by the extension of the arms and legs, not flexion. Therefore, this option does not describe decorticate posturing.

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Exhibits A nurse is providing discharge teaching. Which of the following client statements indicate an understanding of the teaching? Client Statements

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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Exhibits

A nurse is providing discharge teaching. Which of the following client statements indicate an understanding of the teaching?
Client Statements