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: Peptic ulcer disease doesn't typically present with ecchymosis around the umbilicus (Cullen's sign) or significantly elevated amylase and lipase levels.
Choice B rationale: Gastroenteritis is less likely given the specific symptoms, physical exam findings, and laboratory results indicating pancreatic involvement.
Choice C rationale: Acute pancreatitis fits the clinical picture with epigastric pain after heavy alcohol use, persistent nausea/vomiting, tenderness, and elevated amylase and lipase levels.
Choice D rationale: Diverticulitis typically presents with symptoms more localized to the lower abdomen and doesn't cause the characteristic findings seen in this scenario.
Correct Answer is A
Explanation
Choice A rationale: Cri du chat syndrome involves a high-pitched cry in infants and other distinct physical and developmental features, but it doesn't present with the described symptoms.
Choice B rationale: Klinefelter syndrome, characterized by an extra X chromosome (XXY) in males, typically presents with small testicles, gynecomastia (enlarged breast tissues), sexual dysfunction, and altered body proportions, such as long legs and a shorter trunk, aligning with the client's symptoms.
Choice C rationale: Patau syndrome (Trisomy 13) manifests with severe developmental issues, facial abnormalities, and other physical malformations, but the described symptoms are not typically associated with this syndrome.
Choice D rationale: Turner syndrome involves females with a missing or partially missing X chromosome (45, X), resulting in specific physical features and medical problems not consistent with the described symptoms in a male client.

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