An acute care nurse receives a 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?

Pronation of the hands.

Extension of the arms.

External rotation of the lower extremities.

Plantar flexion of the legs.

Answer and Explanation

The Correct Answer is D

Choice A Reason:

Pronation of the hands.

Pronation of the hands is not typically associated with decorticate posturing. Decorticate posturing is characterized by the flexion of the arms and wrists, with the hands often clenched into fists. Pronation refers to the rotation of the hands so that the palms face downward, which is not a feature of decorticate posturing.

Choice B Reason:

Extension of the arms.

Extension of the arms is more characteristic of decerebrate posturing, not decorticate posturing. In decorticate posturing, the arms are flexed and held tightly to the chest, not extended. This flexion is due to damage to the cerebral hemispheres, which affects the corticospinal tract.

Choice C Reason:

External rotation of the lower extremities.

External rotation of the lower extremities is not a typical finding in decorticate posturing. In decorticate posturing, the legs are usually extended and rigid, with the toes pointed. External rotation would indicate a different type of posturing or neurological condition.

Choice D Reason:

Plantar flexion of the legs.

Plantar flexion of the legs is a characteristic finding in decorticate posturing. This involves the toes pointing downward, which is a result of the increased muscle tone and reflexes due to the brain injury. This posture indicates severe damage to the brain, specifically the corticospinal tract.

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Correct Answer is C

Explanation

Choice A reason:

Strict monitoring of hourly intake and output is important for managing fluid balance and detecting potential complications such as dehydration or fluid overload1. However, it is not the highest priority in the acute phase of bacterial meningitis. The primary concern is to monitor for signs of increased intracranial pressure (ICP) and neurological deterioration.

Choice B reason:

Managing pain through drug and non-drug methods is essential for patient comfort and overall well-being. Pain management can help reduce stress and improve the patient’s ability to rest and recover. However, it is not the highest priority compared to monitoring neurological status, which can provide early indications of complications such as increased ICP or seizures.

Choice C reason:

Assessing neurological status at least every 2 to 4 hours is the highest priority for a client with bacterial meningitis. This frequent assessment helps detect early signs of neurological deterioration, increased ICP, and other complications. Early detection and intervention are crucial in preventing severe outcomes and improving the patient’s prognosis.

Choice D reason:

Decreasing environmental stimuli is important to reduce stress and prevent exacerbation of symptoms such as headache and photophobia. While this intervention is beneficial, it is not as critical as frequent neurological assessments in the acute management of bacterial meningitis.

A. Assess the client’s gag reflex before giving any food or water. B. Provide the client with ice chips instead of a drink of water. C. Contact the primary healthcare provider and get the appropriate orders. D. Let the client have a small sip to evaluate the ability to swallow.

Correct Answer is A

Explanation

Choice A Reason:

Assessing the client’s gag reflex before giving any food or water is crucial after a bronchoscopy. The procedure involves the use of local anesthesia to numb the throat, which can impair the gag reflex and increase the risk of aspiration. Ensuring that the gag reflex has returned before allowing the client to eat or drink helps prevent choking and aspiration, which are serious complications.

Choice B Reason:

Providing the client with ice chips instead of a drink of water is not the best initial action. While ice chips may seem like a safer option, they still pose a risk of aspiration if the gag reflex has not fully returned. The priority is to first assess the gag reflex to ensure the client can safely swallow.

Choice C Reason:

Contacting the primary healthcare provider and getting the appropriate orders is not necessary as the first action. The nurse can independently assess the gag reflex, which is a standard nursing practice after procedures involving throat anesthesia. If there are concerns after the assessment, then contacting the healthcare provider would be appropriate.

Choice D Reason:

Letting the client have a small sip to evaluate the ability to swallow is not safe without first assessing the gag reflex. This approach could lead to aspiration if the gag reflex has not returned. The initial step should always be to assess the gag reflex to ensure the client can safely swallow liquids.

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An acute care nurse receives a 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

A client is admitted with bacterial meningitis. Which nursing intervention is the highest priority for this client?

Correct Answer is C

Explanation

A client who had a bronchoscopy 2 hours ago asks for a drink of water. What action would the nurse take initially to assure client safety?

Correct Answer is A

Explanation

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