The nurse is assessing a brain-injured client response to nail bed pressure. The client demonstrates internal rotation, adduction, and flexion of the arms, the nurse should report the response as which finding

Decerebrate posturing

Decorticate posturing

Flexion withdrawal

Localization of pain

Answer and Explanation

The Correct Answer is B

A. Decerebrate posturing: This involves extension and outward rotation of the arms, which is not observed here.

B. Decorticate posturing: Internal rotation, adduction, and flexion of the arms are characteristic of decorticate posturing, indicating damage to the corticospinal tract.

C. Flexion withdrawal: This refers to pulling away from a painful stimulus and does not involve the described pattern of movement.

D. Localization of pain: This is an intentional movement toward the source of pain, which is not demonstrated in this scenario.

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Correct Answer is A

Explanation

A. Remind the client to look for food on the left side of the tray: Homonymous hemianopsia is a condition in which a person loses vision in the same half of the visual field of each eye (in this case, the left visual field due to right-sided brain damage). The nurse should remind the client to look for food on the left side of the tray to help compensate for the visual deficit.

B. Provide a non-skid mat to alleviate plate movement. While a non-skid mat can help with plate stability, it does not address the visual field loss caused by homonymous hemianopsia.

C. Encourage the client to use his right hand when feeding himself. There is no specific benefit to using the right hand when a client is experiencing a visual deficit in the left visual field. Instead, compensating for the visual field loss is the priority.

D. Encourage the use of the wide grip utensils. Wide grip utensils are helpful for clients with limited hand mobility but will not address the specific visual impairment caused by homonymous hemianopsia.

A. Suppresses ectopic ventricular sites B. Increases SA node automaticity C. Increases myocardial contractibility D. Decreases AV node conduction

Correct Answer is B

Explanation

A. Suppresses ectopic ventricular sites: Atropine primarily increases heart rate; it does not directly suppress ectopic ventricular activity.

B. Increases SA node automaticity: Atropine blocks the parasympathetic nervous system, increasing SA node activity and heart rate in cases of bradycardia or asystole.

C. Increases myocardial contractility: This effect is more related to drugs like inotropes (e.g., dopamine), not atropine.

D. Decreases AV node conduction: Atropine actually increases conduction through the AV node by blocking vagal stimulation.

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The nurse is assessing a brain-injured client response to nail bed pressure. The client demonstrates internal rotation, adduction, and flexion of the arms, the nurse should report the response as which finding

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous hernianopsia when eating. Which action should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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