img-download-app
img-download-app

A nurse is making the initial rounds and enters the room of a patient who is suffering from severe brain trauma. The nurse sees the patient with a rigid extension of all extremities. The patient's forearms are hyper-pronated and the feet are plantar-flexed. Which positioning is the patient exhibiting?

Explanation

• Decerebrate positioning is characterized by rigidity in all four extremities with hyper-pronation of the forearms and plantar-flexion of the feet (toes pointed). It usually indicates more severe brain damage than decorticate positioning.

• Patients who are suffering from severe brain trauma may exhibit involuntary responses, namely decorticate and decerebrate positioning.

• Incorrect: Decorticate positioning is characterized by stiffness in all extremities with arms bent (imagine the arms are pulled in towards the "core"), clenched fists, and legs held out straight.

• Incorrect: Opisthotonic positioning is when the patient shows arching of the back and neck. This may be seen in conjunction with decerebrate posturing.

Visit our website for other NCLEX topics now!
Related questions

The nurse is assessing a patient who has been suffering from low back pain for the past three weeks. Which of the following suggests a herniated disc?

The nurse is caring for an immunocompromised patient that has developed histoplasmosis. The nurse assesses the patient knowing that histoplasmosis is similar to pneumonia in that it

A client admitted to the ICU due to unresponsiveness is diagnosed with cerebrovascular accident (CVA) and started on nasogastric tube feedings. As the nurse checks tube placement to prepare for the next feeding, which of the following should be performed for gastric residual greater than 100mL?

The nurse is assessing a patient with psoriasis. The nurse would expect:

A patient is admitted to the hospital with 4th degree burns. The nurse expects the patient's wounds to be:

The nurse is assessing the cardiac rhythm of a patient with coronary artery disease (CAD). The heart monitor shows isolated premature ventricular contractions (PVC). What should the nurse do next?

The nurse is performing a physical assessment on a patient with an aortic dissection. Which of the following should the nurse avoid during the physical assessment?

The nurse assesses a patient complaining of chest pain that radiates down the left arm. The patient is diaphoretic and short of breath. What should the nurse do next?

A patient suspected of having testicular cancer is being interviewed by the nurse. Among the data gathered by the nurse, which is the most significant in determining the risk of testicular cancer?

A patient is brought into the emergency department with a pheochromocytoma. In order to reverse the lethal symptoms of this disease, the nurse prepares to infuse

A patient is admitted to the hospital after a metastatic tumor was found in their liver. The patient asks whether a person can have a metastatic tumor without having primary cancer. Which of the following statements is correct?

The nurse is preparing an exercise program to increase range-of-motion and mobility for a post-stroke patient. The initial exercises start with passive movement. Which of the following activities should be done?

The nurse is teaching an adult patient diagnosed with bladder cancer about the signs and symptoms of chemo-induced thrombocytopenia, which include

A patient diagnosed with ovarian cancer has been informed that it has spread to her liver and pancreas. What does this refer to?

The nurse is caring for a patient on a mechanical ventilator due to respiratory failure. The ventilator is set at a FiO2 of 80% with orders to titrate down as tolerated. The nurse understands that the FiO2 goal is to be less than which percent to decrease the risk of complications?

The nurse is preparing to obtain a urine culture from a patient with an indwelling catheter. To collect the specimen, the nurse should:

The nurse is caring for a patient with Cushing's syndrome who is scheduled for a transsphenoidal hypophysectomy. Before the surgery, which of the following interventions is appropriate to assess the patient for potential complications?

The nurse is caring for a patient with an adenoma of the adrenal cortex. The nurse should be alert for symptoms related to the secretion of which substance?

A patient with chronic renal failure is being treated with continuous ambulatory peritoneal dialysis (CAPD). The nurse realizes this process:

A patient with hepatitis is admitted to the hospital. The physician believes he contracted the disease from contaminated food. Which of the following is most likely the diagnosis?

A nurse is assessing a patient with glomerulonephritis. The nurse asks the patient about a recent history of:

The nurse is reviewing the results of genetic testing of a patient with sickle cell disease, noting that HbS indicates sickle cell disease, HbAS indicates sickle cell trait, and HbA indicates normal hemoglobin. The patient and her husband are at the lowest risk of having a child with sickle cell disease if

A hospitalized patient is in the oliguric phase of acute renal failure. The nurse should implement which of the following?

The nurse is assessing a patient with a barrel chest. The nurse explains to the patient that this is caused by which disease?

A client is admitted to the medical department due to pneumonia associated with influenza. Which of the following interventions promotes airway patency? 

A patient with renal failure has developed uremic syndrome. While assessing this patient, the nurse would expect to note which of the following?

A patient with a closed head injury is admitted to the hospital. The nurse observes a yellow ring around a clear moist area on the patient’s pillow. The nurse is correct by thinking that this finding is

The nurse assesses a patient suspected of having a pleural effusion. Which of the following are the most common clinical manifestations of this condition?

The nurse is administering an enema to a client. The nurse positions the client side-lying and inserts the lubricated tip of the enema applicator to a depth of:

A 37-year-old patient involved in a motor vehicle accident sustained a head injury resulting in a subdural hematoma. The nurse caring for the patient noticed that he was confused but later on became unresponsive with a blood pressure of 100/60 mmHg. As the nurse transports the patient to the operating room, which of the following is the most effective position for the patient?

The nurse is caring for a patient who underwent a fasciotomy for the treatment of compartment syndrome. Which type of dressing should the nurse prepare to cover the site?

Which of the following cancers is more prevalent in teenagers and young adults?

The nurse is performing an admission assessment on a patient who was recently diagnosed with Hodgkin's disease. Of the following signs, which would the nurse expect the patient to report?

A patient with a severe allergy to dust mites is receiving instructions from the nurse. Which of the following will help with this reaction?

A nurse caring for a 50-year-old newly diagnosed with Parkinson's disease would want to educate the patient and their family about which of the following symptoms? 

The nurse is educating adolescents on the best ways to reduce cancer risks. Which of the following factors should be included?

A nurse is assessing a patient with bilateral hand burns and singed arm hair. The nurse identifies this type of burn as:

A patient with myasthenia gravis receives pyridostigmine from the newly-hired licensed practical nurse (LPN). The LPN is practicing safe medication administration if the LPN

A patient is admitted to the hospital due to a myocardial infarction. Which of the following interventions or devices would increase coronary perfusion and decrease cardiac workload?