The nurse recognizes that which of the following assessment observations of a comatose client has the greatest implication?
1. Both arms are extended and adducted and with the palms facing down.
2. Arms, wrist, and fingers are flexed and adducted.
3. Muscles of the entire upper extremities are flaccid bilaterally.
4. Fasciculational twitching occurs in the small muscle groups of both arms.
Both arms are extended and adducted and with the palms facing down.
Rationale: Both arms are extended and adducted and with the palms facing down describes decerebrate posturing, believed to be the most grave of the responses provided as options. Arms, wrist, and fingers are flexed and adducted describes decorticate posturing. Muscles of the entire upper extremities are flaccid bilaterally describes paralysis, while fasciculational twitching is involuntary, arising from the spontaneous discharge of a bundle of skeletal muscle fibers, and is usually benign.
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