Which term would the nurse use to document a patient who is comatose from a head injury and display flexion of the arms, wrists, and fingers, as well as adduction of the upper extremities?

Decorticate posturing

Epileptic

Stroke

Decerebrate posturing

Answer and Explanation

The Correct Answer is A

A.   Decorticate posturing indicates severe brain injury, characterized by flexion of the arms and adduction of the upper extremities.
B.   Epileptic is not a term used to describe posturing related to head injury.
C.   Stroke does not describe posturing.
D.   Decerebrate posturing is characterized by extension and pronation of the arms, not flexion.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Thrombotic stroke typically presents with gradual symptom onset, not the sudden headache and vomiting seen here.
B. Embolic stroke is associated with symptoms that appear suddenly and usually do not present with vomiting or seizures.
C. A hemorrhagic stroke is characterized by the sudden onset of a severe headache, vomiting, altered mental status, and sometimes seizures, which are all present in this patient. The high blood pressure and fever may indicate a hemorrhage in the brain or an associated infection.
D. Transient ischemic attack (TIA) presents with temporary neurological deficits and does not cause persistent symptoms like a seizure or vomiting.

A. BP 126/54 mm Hg, pulse 58 beats/min, respirations 10 breaths/min B. BP 112/56 mm Hg, pulse 98 beats/min, respirations 28 breaths/min C. BP 129/65 mm Hg, pulse 60 beats/min, respirations 20 breaths/min D. BP 172/54 mm Hg, pulse 58 beats/min, respirations 10 breaths/min

Correct Answer is D

Explanation

A. BP 126/54 mm Hg, pulse 58 beats/min, respirations 10 breaths/min - While the low pulse and respirations should be assessed, this blood pressure isn't as concerning.
B. BP 112/56 mm Hg, pulse 98 beats/min, respirations 28 breaths/min - These vital signs are within a safer range compared to the critical changes in D.
C. BP 129/65 mm Hg, pulse 60 beats/min, respirations 20 breaths/min - These are stable vital signs.
D. The BP of 172/54 mm Hg, combined with bradycardia (pulse of 58 beats/min) and hypoventilation (respirations of 10 breaths/min), is indicative of Cushing's triad, a late sign of increased intracranial pressure, which is an emergency requiring immediate attention.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Which term would the nurse use to document a patient who is comatose from a head injury and display flexion of the arms, wrists, and fingers, as well as adduction of the upper extremities?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

When the patient's initial vital signs after a brain injury were a BP of 132/72 mm Hg, pulse 100 beats/min, respirations 24 breaths/min, which subsequent vital signs would the nurse report immediately to the health care provider?

Correct Answer is D

Explanation

For the patient who wears contact lenses, which intervention would the nurse teach the patient when diagnoses with bacterial conjunctivitis?

A nurse is teaching an older adult client who has diabetes mellitus about preventing the long- term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include?

To preserve cerebral perfusion of a patient with an elevated intracranial pressure (ICP), which cerebral perfusion pressure (CPP) would the nurse maintain when suctioning the patient?

An RN is teaching a student nurse about tissue plasminogen activator (tPA) administration in a patient with ischemic stroke. Which statement made by the student nurse indicates a need for further teaching?

Which intervention would the nurse implement to provide relief of the patient's discomfort when presenting to the clinic with a red, swollen, circumscribed, acutely, tender area near the eye and in the lid margin?

A nurse is performing a home safety assessment for a client who has experienced a stroke. Which of the following findings are a safety hazards for the client?

A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?

A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program?