In the Neuro ICU, a comatose patient has this posture in bed: Upper arms are flexed tight to the sides with elbows, wrists, and fingers flexed. The legs are extended and internally rotated. The nurse interprets this posture as:

Decorticate Rigidity

Flaccid

Decerebrate Rigidity

Hemiplegia

Answer and Explanation

The Correct Answer is A

A.   Decorticate rigidity is characterized by flexion of the arms and extension of the legs. In this posture, the upper arms are flexed and held tightly to the sides, with the elbows, wrists, and fingers also flexed. The legs are extended and internally rotated.
B.   Flaccid posture, or flaccidity, is characterized by a complete lack of muscle tone, which leads to a limp and lifeless appearance. There is no resistance to passive movement, and the muscles are weak or paralyzed.

C.   Decerebrate rigidity is characterized by extension of both the arms and the legs. In this posture, the arms are extended at the sides with the wrists and fingers flexed, and the legs are extended and internally rotated. This type of rigidity indicates damage to the brainstem below the red nucleus.
D.   Hemiplegia refers to paralysis of one side of the body, which can result from brain injury or stroke affecting one hemisphere of the brain. The affected side will have limited or no movement and muscle tone.

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Correct Answer is A

Explanation

A. Flight of ideas is characterized by a rapid and continuous flow of thoughts where the individual frequently shifts topics, often making it difficult to follow their conversation. This is commonly observed in conditions like mania or hypomania, often seen in bipolar disorder.
B. Confabulation involves fabricating or inventing stories or information to fill in gaps in memory. It is often seen in conditions affecting memory or cognition, such as Korsakoff’s syndrome or certain types of dementia.
C. Depression typically involves symptoms such as low mood, decreased energy, and lack of interest in activities, rather than rapid speech or topic shifts. The client’s accelerated pace of speech and jumping from topic to topic do not align with the characteristics of depression.
D. Schizophrenia is a broad term for a range of symptoms, including hallucinations, delusions, disorganized thinking, and impaired social functioning. While disorganized thinking can be a symptom of schizophrenia, the specific behavior described (accelerated speech and jumping topics) more specifically indicates flight of ideas, which is not exclusive to schizophrenia.

A. Asked the client to swallow B. Asked the client to extend the tongue C. Asked the client to rock the jaw laterally D. Asked the client to open and close the mouth E. Asked the client to jut the jaw forward

Correct Answer is ["C","D","E"]

Explanation

A. Swallowing involves the muscles of the throat and esophagus rather than the TMJ.
B. Extending the tongue involves the muscles of the tongue and mouth, which are not directly related to the TMJ.
C. Rocking the jaw laterally (side to side) is a specific movement that involves the TMJ. This movement tests the ability of the TMJ to move the jaw from side to side.
D. Opening and closing the mouth involves the primary hinge movement of the TMJ. This movement assesses the vertical range of motion of the jaw.
E. Jutting the jaw forward (protrusion) involves moving the lower jaw forward in relation to the upper jaw. This movement tests the ability of the TMJ to perform anterior movement.

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In the Neuro ICU, a comatose patient has this posture in bed: Upper arms are flexed tight to the sides with elbows, wrists, and fingers flexed. The legs are extended and internally rotated. The nurse interprets this posture as:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is admitting a client to the unit for surgery the next morning. The nurse notes that the client speaks at an accelerated pace and jumps from topic to topic no of which progresses to sensible conversation. What would the nurse document about this client?

Correct Answer is A

Explanation

After a physical assessment, the nurse determines that a client has full range of motion of the temporomandibular joint. Which of the following assessments did the nurse complete with the client? Select all that apply.

Correct Answer is ["C","D","E"]

Explanation

When implementing nursing interventions for a client who has attempted suicide, which of the following is most important?

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Stroke Warning signs includes? Select all that applied.

The client presents to the nurse stating that his jaws feel "stuck". What joint should the nurse assess?

A client is able to actively move the right arm against gravity. How should the nurse document this finding using the muscle strength grading?

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A nurse is performing a physical examination on a patient. When the patient is asked to protrude his tongue, the nurse noticed a deviation from the midline to the right side. This is related to a lesion of: