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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Cerebrospinal fluid is cloudy in nature. Cloudy cerebrospinal fluid is a sign of infection or inflammation in the central nervous system, and lumbar puncture can be used to obtain cerebrospinal fluid for diagnostic purposes. The nurse should report this finding immediately to the physician for further evaluation and management.

Choice A, client states a piercing feeling, is incorrect because a piercing feeling is common during the procedure due to the insertion of the needle into the subarachnoid space.

Choice B, physician maintains aseptic procedure, is incorrect because maintaining aseptic technique during the procedure is standard protocol to prevent infection.

Choice C, client states a pressure relief in the head, is incorrect because this is not a concerning finding during the procedure.

A. Use aseptic technique. B. Use an applicator only once. C. Gently remove crusts around pin sites. D. Clean the site, working toward the pin. E. Obtain culture if purulent drainage.

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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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assisting the physician in completing a lumbar puncture. Which would the nurse note as a concern?

Correct Answer is D

Explanation

When performing pin care, which of the following would be most appropriate? Select all that apply.

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

Explanation

The nurse is caring for a group of breast cancer survivors postmastectomy. When developing a list of instructions of points to avoid, which point is highlighted?

A client, who is recovering from bariatric surgery, is eating from a po [portable commode]. Nursing assessment is of greatest concern in the immediate postoperative period for which of the following?

A suspicious breast lump is noted on a mammogram. The client asks the nurse which diagnostic test confirms if the lump is cancerous or benign. Which response by the nurse is most correct?

The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician?

The nurse is assessing a 2-year-old client who has sustained a fracture from falling off a slide while playing in the park. What type of fracture did the child most likely sustain?

Which nursing instruction is correct to provide the client following a barium enema?

The nurse is instructing a 3-year-old's mother regarding abnormal findings within the urinary system. Which assessment finding would the nurse document as normal finding for this age group?

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