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","B","C","E"]

Explanation

A. Bring the crash cart to the bedside: Essential for advanced cardiac life support (ACLS), including defibrillation and medications.

B. Start cardiopulmonary resuscitation: High-quality CPR is critical to maintain circulation until defibrillation can occur.

C. Defibrillate the client: Defibrillation is the definitive treatment for ventricular fibrillation to restore a normal rhythm.

D. Administer adenosine (Adenocard) to assist in determining the rhythm: Adenosine is used for diagnosing or treating certain supraventricular tachycardias, not ventricular fibrillation.

E. Consider the "Hs and Ts": Identifying reversible causes of cardiac arrest (e.g., hypoxia, hypothermia, toxins) is part of the ACLS protocol.

A. Sinus rhythm with first-degree heart block B. ST-segment elevation myocardial infarction (STEMI) C. Atrial fibrillation D. Ventricular tachycardia

Correct Answer is B

Explanation

A. Sinus rhythm with first-degree heart block: This rhythm is characterized by a regular sinus rhythm with a prolonged PR interval (greater than 0.20 seconds), indicating a first-degree heart block.

B. ST-segment elevation myocardial infarction (STEMI): STEMI is indicated by significant ST-segment elevation in specific leads, showing acute myocardial infarction.

C. Atrial fibrillation: Atrial fibrillation shows an irregularly irregular rhythm without distinct P waves.

D. Ventricular tachycardia: Ventricular tachycardia is a rapid heart rhythm originating from the ventricles, with wide QRS complexes and no preceding P waves.

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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

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Naxlex Comprehensive Predictor Exams

The client is found in ventricular fibrillation. What interventions should the team implement? Select All That Apply

Correct Answer is ["A","B","C","E"]

Explanation

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Correct Answer is B

Explanation

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