When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, how should the nurse report the response?
Localization of pain
Decorticate posturing
Decerebrate posturing
Flexion withdrawal
The Correct Answer is B
Choice A rationale: Localization of pain refers to the ability of an individual to pinpoint the exact location of pain, which is different from the described response.
Choice B rationale: Decorticate posturing involves the arms flexing inward toward the body, which is consistent with the observed response to nail bed pressure.
Choice C rationale: Decerebrate posturing involves extension and outward rotation of the arms, which is different from the described response.
Choice D rationale: Flexion withdrawal typically involves pulling away from a painful stimulus, which differs from the specific response observed in the scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: This is a general description of an imaging test, such as an X-ray, ultrasound, or MRI, which can show the structure of the organs but not the mucosal lining.
Choice B rationale: This is a general description of a blood test, which can show signs of infection, inflammation, or anemia, but not the cause of these problems.
Choice C rationale: This exam is called a colonoscopy, which involves inserting a flexible tube with a camera and light into the anus and advancing it through the colon. A colonoscopy can reveal signs of inflammation, ulcers, bleeding, or narrowing of the intestinal wall that are characteristic of Crohn's disease. A biopsy can also be taken during the procedure to confirm the diagnosis.
Choice D rationale: This is a general description of a urine test, which can show signs of kidney problems, urinary tract infections, or dehydration, but not Crohn's disease.
Correct Answer is C
Explanation
Choice A rationale: Kayexalate is not primarily used for phosphate reduction.
Choice B rationale: Kayexalate can have sorbitol in its formulation, which might cause diarrhea rather than constipation.
Choice C rationale: Kayexalate works as a cation-exchange resin that promotes potassium excretion in the bowels.
Choice D rationale: Kayexalate does not add potassium; it exchanges sodium for potassium in the bowels.
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