A nurse is caring for a client with deteriorating neurologic status. The nurse is performing an assessment at the beginning of the shift that reveals a falling blood pressure and heart rate, and the client makes no motor response to stimuli
Which documentation of neuromuscular status is most appropriate? A) Abnormal posture
B) Flaccidity
C) Weak muscular tone
D) Decorticate posturing
B
Feedback:
The nurse would document flaccidity when the client makes no motor response to stimuli. Abnormal posturing and weak motor tone would be documented specifically as the nurse would assess. Decorticate posturing is when a client is stiff with bent arms and clenched fists with legs straight out.
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