The nurse is planning to assess an adult patient with a neurological problem for abnormal posturing. For what postures should the nurse specifically assess?
Select all that apply.
1. decorticate
2. decerebrate
3. circumduction
4. festinating
5. nystagmus
Correct Answer: 1, 2
In decorticate posturing, the upper arms are close to the sides; the elbows, wrists, and fingers are flexed; the legs are extended with internal rotation; and the feet are plantar flexed. In decerebrate posturing, the neck is extended; the jaw is clenched; the arms are pronated, extended, and close to the sides; the legs are extended straight out; and the feet are plantar flexed. Festinating describes a gait abnormality, and circumduction refers to the circular movement of a limb. Nystagmus is the term for involuntary eye movements seen in stroke patients.
You might also like to view...
A patient with schizophrenia had an exacerbation related to medication noncompliance. During 4 days of hospitalization, medication was resumed. The patient's thought processes are now more organized, and discharge is planned
The patient's family is upset and tells the nurse, "It's too soon for discharge. We will just go through all this again." The nurse should: a. call the psychiatrist to explain the discharge rationale. b. explain that health insurance will not pay for a longer stay. c. call security to handle the disturbance, and escort the family off the unit. d. explain that the patient will continue to improve if medication is taken regularly.
When caring for an ill adult client, the nurse is particularly concerned that the client communicates well since:
a. Assessment, planning of care and even the therapeutic relationship is based on effective communication b. It is the social connection that all individuals base interpersonal relationships upon c. How well an individual communicates is a reflection on both their physical and emotional well-being d. The need to communicate is a basic need of all individuals
The nurse is caring for a client with Ménière's disease. What does the nurse recommend to the client to reduce the symptoms of vertigo?
a. "Take salt and potassium supplements daily." b. "Drink at least eight glasses of water every day." c. "Blow your nose hard when dizziness first begins." d. "When dizziness begins, lie down and keep your head still."
Because midwifery does not possess a unique body of knowledge, it cannot be considered to be a profession
Indicate whether the statement is true or false.