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. A high-pitched cry, often described as a "crying in pain" or "irritable cry," can be a characteristic sign of meningitis in infants. The cry may sound different from the infant's usual cry and may be associated with irritability, discomfort, or pain. It can be indicative of increased intracranial pressure and neurological irritation caused by the inflammation of the meninges.
A. Constipation is not typically associated with meningitis in infants. Meningitis is an inflammation of the membranes surrounding the brain and spinal cord, which can cause symptoms such as fever, irritability, poor feeding, vomiting, and lethargy.
B. A depressed anterior fontanel (sunken soft spot on the baby's head) is not a typical manifestation of meningitis. Meningitis may cause signs of increased intracranial pressure, such as a bulging fontanel, rather than a depressed fontanel.
C. he presence of the rooting reflex is not specific to meningitis. The rooting reflex is a normal reflex present in infants, where they turn their head toward a stimulus (such as stroking the cheek or corner of the mouth) in search of nourishment (typically the breast or bottle).
Correct Answer is ["A","B"]
Explanation
A. Humidified oxygen can help improve oxygenation and relieve respiratory distress by maintaining optimal humidity levels in the airways, which can be beneficial, especially in infants with bronchiolitis who may have increased respiratory secretions and airway inflammation.
B. Monitoring respiratory rate and oxygen saturation allows for early detection of respiratory distress and hypoxemia, which are common complications of bronchiolitis. Regular assessment helps guide interventions and ensures timely escalation of care if needed.
C. Restricting fluid intake is not typically indicated for children with bronchiolitis. In fact, maintaining adequate hydration is crucial for children with respiratory illnesses to help thin respiratory secretions and prevent dehydration.
D. Antibiotics are not routinely indicated for the treatment of bronchiolitis caused by viral pathogens. Bronchiolitis is typically caused by respiratory syncytial virus (RSV) or other viral infections, for which antibiotics are ineffective.
E. Chest physiotherapy is not routinely recommended for the management of bronchiolitis in infants and children. Bronchiolitis is primarily managed with supportive care measures such as humidified oxygen, hydration, and monitoring for respiratory distress.
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