The nurse is caring for a client with a deteriorating neurological condition. The nurse is performing an assessment at the beginning of the shift and notes a falling blood pressure and heart rate. The client is lying flat with arms and legs that are extended, stiff, and rigid, and the feet are plantar flexed. What would be the correct documentation of this posturing?
Stuporous.
Decerebrate.
Decorticate.
Flaccidity.
The Correct Answer is B
Choice A is incorrect because stuporous is a state of reduced consciousness, and does not describe the posturing observed in the client.
Choice B is correct because decerebrate posturing is characterized by extension of the arms, wrists, and fingers, and extension and internal rotation of the legs, with plantar flexion of the feet.
Choice C is incorrect - Decorticate posturing is characterized by flexion of the arms, wrists, and fingers, extension, internal rotation, and adduction of the legs, with plantar flexion of the feet. This is caused by damage to the cerebral cortex and is indicative of a neurological problem.
Choice D is incorrect because flaccidity is a state of complete lack of muscle tone, and does not describe the posturing observed in the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Abandon biases that older adults are sexually inactive. Older adults are sexually active and at risk for sexually transmitted infections (STIs). The nurse should not make assumptions about the client's sexual activity based on age.
Option A, older clients who are sexually active have less risk for STIs than other age groups, is incorrect because older adults are at risk for STIs. Option C, older clients know the ways to prevent STIs, may not always be accurate.
Option D, older clients, because of their maturity, are rarely embarrassed to talk about it, is a generalization and may not be true for all older clients.
Correct Answer is ["A","B","D","E"]
Explanation
When performing pin care, the nurse should use aseptic technique and obtain a culture if purulent drainage is present. The applicator should be used only once, and the site should be cleaned, working toward the pin. Crusts around the pin site should not be removed as this can cause trauma to the site and increase the risk of infection.
Choice C, Gently remove crusts around pin sites is not appropriate as this can cause trauma to the site and increase the risk of infection.
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