During an assessment of a 32-year-old patient with a recent head injury, the nurse notices that the patient responds to pain by extending, adducting, and internally rotating his arms. His palms pronate, and his lower extremities extend with
plantar flexion. Which statement concerning these findings is most accurate? This patient's response:
a.
Indicates a lesion of the cerebral cortex.
b.
Indicates a completely nonfunctional brainstem.
c.
Is normal and will go away in 24 to 48 hours.
d.
Is a very ominous sign and may indicate brainstem injury.
ANS: D
These findings are all indicative of decerebrate rigidity, which is a very ominous condition and may indicate a brainstem injury.
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