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.
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Related Questions
Correct Answer is D
Explanation
A. Difficulty moving the upper extremities may occur in some stroke patients but is not a direct complication of immobility.
B. Stiffness in the lower extremities could be a result of immobility, but pressure ulcers are a higher immediate concern.
C. Difficulty hearing some types of sounds is unrelated to immobility.
D. Immobility increases the risk of pressure ulcers, especially over bony prominences like the sacrum. A reddened area indicates potential early tissue damage due to prolonged pressure.
Correct Answer is A
Explanation
A. Blepharitis is an inflammation of the eyelid margin causing symptoms such as itching, irritation, light intolerance, and crusting.
B. Retinal detachment involves sudden visual disturbances such as flashes of light or a curtain-like shadow, not itching or crusting.
C. Allergic conjunctivitis involves redness, itching, and watery discharge, not crusty debris on the lid margins.
D. Cataracts lead to blurred vision and glare, not irritation or crusting.
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