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

Answer and Explanation

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.

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Correct Answer is B

Explanation

B. Leaning forward with the chin thrust out, often described as the "sniffing position," is a classic sign of airway obstruction, particularly in cases of epiglottitis. This positioning helps to maximize airway patency by opening the airway and reducing the risk of further obstruction.

A. Leaning forward with the chin thrust out is not typically associated with extreme fatigue. Instead, it is a specific positioning often seen in individuals with epiglottitis to help alleviate airway obstruction and facilitate breathing.

C. Leaning forward with the chin thrust out is not indicative of dehydration. Dehydration may present with other signs and symptoms such as dry mucous membranes, decreased urine output, sunken fontanelle (in infants), and poor skin turgor.

D. Pain may be present in a child with epiglottitis but leaning forward with the chin thrust out is not primarily indicative of pain. This positioning is primarily a compensatory mechanism to alleviate airway obstruction rather than a response to pain.

A. Frequent swallowing B. Reports of thirst C. Reports of pain D. Mouth breathing

Correct Answer is A

Explanation

A. Frequent swallowing is a common finding after a tonsillectomy due to postoperative throat discomfort and the sensation of having a foreign object in the throat (such as blood clots or mucus).

B. Reports of thirst may indicate dehydration, which can occur after surgery, especially if the child is not drinking enough fluids due to pain or discomfort. While dehydration can be a concern after a tonsillectomy, it is not a specific sign of hemorrhage.

C. Pain is common after a tonsillectomy and can be expected in the postoperative period. While increased pain may be present if hemorrhage occurs, it is not a specific sign of hemorrhage on its own.

D.Mouth breathing does not directly indicate bleeding and is more related to discomfort or difficulty breathing through the nose, especially if the child is experiencing throat pain. It is not a typical sign of hemorrhage.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse employed in an emergency department is instructed to monitor a child diagnosed with epiglottitis. The nurse notes that the child is leaning forward with the chin thrust out. The nurse interprets this observation as indicating which finding?

Correct Answer is B

Explanation

A nurse is monitoring a child who is postoperative following a tonsillectomy for signs of hemorrhage. Which of the following findings is a sign of this postoperative complication?

Correct Answer is A

Explanation

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