The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing?
Adduction of the arms at the shoulders
Abnormal flexion of the upper extremities and extension and adduction of lower extremities
Flaccid paralysis of all extremities
Rigid extension and pronation of the arms and legs
The Correct Answer is D
D. This is the correct characteristic of decerebrate posturing. Decerebrate posturing is characterized by rigid extension and pronation (turning inward) of the arms and legs. It indicates severe neurological dysfunction and increased intracranial pressure, often involving damage to the brainstem.
A. This characteristic is not associated with decerebrate posturing. Adduction refers to movement toward the midline of the body, which is not typically observed in decerebrate posturing.
B. This description is not characteristic of decerebrate posturing. Decerebrate posturing involves extension, not flexion, of the upper extremities, along with extension and pronation (not adduction) of the lower extremities.
C. Flaccid paralysis refers to the absence of muscle tone and movement, which is not characteristic of decerebrate posturing. Decerebrate posturing involves increased muscle tone and abnormal, rigid extension of the arms and legs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. If the tympanostomy tubes fall out, the parent should contact the healthcare clinic or the healthcare provider who performed the procedure. They can provide guidance on whether the child needs to be seen for an evaluation and potential replacement of the tubes. Reporting the situation allows for appropriate follow-up and management by the healthcare team.
A. Tympanostomy tubes are small tubes inserted into the eardrums to help drain fluid from the middle ear and prevent recurrent ear infections. While they are designed to stay in place for a certain period, it is possible for them to fall out prematurely.
B. It's important for the parent to seek medical advice if the tubes fall out but it may not always require an immediate visit to the emergency department. However, if the child experiences severe pain, bleeding, or signs of infection after the tubes fall out, seeking urgent medical attention may be warranted.
C. Only a healthcare provider should insert or reinsert tympanostomy tubes. Attempting to reinsert the tubes at home without proper training and equipment could cause injury or damage to the ear.
Correct Answer is B
Explanation
B Kawasaki disease primarily affects medium-sized arteries, including the coronary arteries. The inflammation associated with Kawasaki disease can weaken the walls of the blood vessels, leading to the formation of aneurysms, particularly in the coronary arteries. Coronary artery aneurysms are a hallmark complication of Kawasaki disease and can increase the risk of myocardial infarction and other cardiovascular problems.
A This option describes a possible consequence of Kawasaki disease. Kawasaki disease can cause inflammation of the blood vessels, including the coronary arteries, which can lead to the formation of coronary artery aneurysms. These aneurysms can disrupt blood flow to the heart muscle, leading to ischemia and potentially heart failure.
C Mitral valve stenosis is not a typical complication of Kawasaki disease. While Kawasaki disease can affect the cardiovascular system and lead to complications such as coronary artery aneurysms, it does not typically cause mitral valve stenosis.
D Atherosclerosis is not a direct consequence of Kawasaki disease. Kawasaki disease primarily involves inflammation of the blood vessels rather than changes in lipid levels, which are more commonly associated with conditions such as hyperlipidemia or familial hypercholesterolemia.
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