A nurse assesses a client and notes the client's position as indicated in the illustration below:
How should the nurse document this finding?
a.
Decorticate posturing
b.
Decerebrate posturing
c.
Atypical hyperreflexia
d.
Spinal cord degeneration
ANS: A
The client is demonstrating decorticate posturing, which is seen with interruption in the corticospinal pathway. This finding is abnormal and is a sign that the client's condition has deteriorated. The physician, the charge nurse, and other health care team members should be notified immediately of this change in status. Decerebrate posturing consists of external rotation and extension of the extremities. Hyperreflexes present as increased reflex responses. Spinal cord degeneration presents frequently with pain and discomfort.
You might also like to view...
Match the pain theory to the correct physiologic basis for the pain
A. Specificity theory 1. Light touch applied to the skin would produce the sensation of touch through low-frequency firing of the receptor. B. Pattern theory 2. Repeated sweeping of a soft-bristled brush on the skin over or near a painful area may result in pain reduction for several minutes. C. Gate control theory 3. Proposes that the brain contains a widely distributed neural network that contains somatosensory, limbic, and thalamocortical components. D. Neuromatrix theory 4. Describes how an acute injury is predicted to be but does not take into account the person's feelings of how the pain feels to him or her.
Nursing care in the fourth trimester includes an important intervention sometimes referred to as taking the time to mother the mother. Specifically this expression refers to:
a. Formally initializing individualized care by confirming the woman's and infant's identification (ID) numbers on their respective wrist bands. ("This is your baby."). b. Teaching the mother to check the identity of any person who comes to remove the baby from the room. ("It's a dangerous world out there.") c. Including other family members in the teaching of self-care and child care. ("We're all in this together.") d. Nurturing the woman by providing encouragement and support as she takes on the many tasks of motherhood.
The nurse manager is working on strategies to turn conflict into collaboration by creating a climate in which participants view negotiation as a collaborative effort. In order to accomplish this goal, the nurse manager works to promote
a. offering of feedback on an infrequent basis. b. clarification of role expectations. c. minimal participation in organizational interdisciplinary groups. d. absence of role-modeling behaviors related to communication.
A nurse is working with a family of a child who is hospitalized with asthma. The family members speak little English, and the child is being sent home on nebulizer treatments as well as an inhaler
In addition to enlisting an interpreter to help with the language barrier, the nurse should: 1. Provide written instructions before discharge. 2. Address any healing beliefs the family has. 3. Make sure the child comes back for the follow-up appointment. 4. Make sure the parents can set up the treatments for their child.