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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Monitoring for CSF leakage is crucial to avoid infection and to maintain ICP accuracy.
B. Hyper-oxygenation may be used in certain cases but is not the priority.
C. Aseptic technique for all procedures and dressing changes is critical to prevent infection.
D. Administering IV mannitol can be important, but aseptic technique is the priority to prevent infection.
Correct Answer is C
Explanation
A. Tachycardia is more commonly associated with early stages of shock or compensation but is not a specific sign of increased ICP.
B. Amnesia may occur with a traumatic brain injury, but it is not a direct sign of increased ICP.
C. Restlessness or agitation is an early sign of increased ICP, as the brain becomes more impaired due to pressure, leading to confusion and changes in behavior.
D. Hypotension is not typically associated with increased ICP. In fact, as ICP rises, there may be compensatory mechanisms that maintain blood pressure, and in later stages, the blood pressure may rise.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
