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 A

Explanation

A. Ice pops are often recommended after tonsillectomy to help soothe the throat and provide hydration.

B.Although ice cream is cold and can soothe the throat, it is not the best option immediately after surgery. Dairy products, including ice cream, can sometimes lead to increased mucus production, which could irritate the throat and make swallowing more difficult during the healing process.

C. Offering hot tea is not recommended immediately following a tonsillectomy. Hot beverages, including tea, can increase the risk of bleeding and discomfort at the surgical site.

D. Cranberry juice is not an appropriate choice immediately post-tonsillectomy. While hydration is essential for recovery, acidic or tart beverages like cranberry juice may irritate the surgical site and increase discomfort.

A. Altered blood flow increases cardiac workload with resulting heart failure. B. Inflammation weakens blood vessels, leading to aneurysm. C. Untreated disease causes mitral valve stenosis. D. Increased lipid levels lead to the development of atherosclerosis.

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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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

A nurse is caring for a client who is postoperative immediately following a tonsillectomy. Which of the following snacks should the nurse offer the client?

Correct Answer is A

Explanation

The nurse is caring for a child with a diagnosis of Kawasaki disease. The child's parent asks the nurse, "How does Kawasaki disease affect my child's heart and blood vessels?" On what understanding is the nurse's response based?

Correct Answer is B

Explanation

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