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The nurse who has been closely monitoring a child who has been exhibiting decorticate (flexor) posturing notes that the child suddenly exhibits decerebrate (extensor) posturing. The nurse interprets that this change in the child's posturing indicates what?
- A. An insignificant finding
- B. An improvement in condition
- C. Decreasing intracranial pressure
- D. Deteriorating neurological function
Correct Answer: D
Rationale: The progression from decorticate to decerebrate posturing usually indicates deteriorating neurological function and warrants primary health care provider notification. Options 1, 2, and 3 are inaccurate interpretations.
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A client is scheduled for a subtotal gastrectomy (Billroth II procedure). The nurse explains that the procedure will have which surgical results?
- A. Proximal end of the distal stomach is anastomosed to the duodenum.
- B. Entire stomach is removed and the esophagus is anastomosed to the duodenum.
- C. Lower portion of the stomach is removed and the remainder is anastomosed to the jejunum.
- D. Antrum of the stomach is removed and the remaining portion is anastomosed to the duodenum.
Correct Answer: C
Rationale: In the Billroth II procedure, the lower portion of the stomach is removed and the remainder is anastomosed to the jejunum. The duodenal stump is preserved to permit bile flow to the jejunum. Options 1, 2, and 4 are incorrect descriptions.
While providing care to a client with a head injury, the nurse notes that a client exhibits this posture (refer to figure). What should the nurse document that the client is exhibiting?
- A. Flaccidity
- B. Decorticate posturing
- C. Decerebrate posturing
- D. Rigidity in the upper extremities
Correct Answer: B
Rationale: Decortication is abnormal posturing seen in the client with lesions that interrupt the corticospinal pathways. In this posturing, the client's arms, wrists, and fingers are flexed with internal rotation and plantar flexion of the feet and legs extended. Flaccidity indicates weak, soft, and flabby muscles that lack normal muscle tone. Decerebration is abnormal posturing and rigidity characterized by extension of the arms and legs, pronation of the arms, plantar flexion, and opisthotonos. Decerebration is usually associated with dysfunction in the brainstem area. Rigidity indicates hardness, stiffness, or inflexibility. Decerebrate posturing is associated with rigidity.
A client states, 'I'm sure I have restless leg syndrome.' The nurse determines that the client is in need of further teaching on the condition when the client identifies the presence of which characteristics? Select all that apply.
- A. A heavy feeling in the legs
- B. Burning sensations in the limbs
- C. Symptom relief when lying down
- D. Decreased ability to move the legs
- E. Symptoms that are worse in the morning
- F. Feeling the need to move the limbs repeatedly
Correct Answer: A,C,D,E
Rationale: Restless leg syndrome is characterized by leg paresthesia associated with an irresistible urge to move. The client complains of intense burning or 'crawling-type' sensations in the limbs and subsequently feels the need to move the limbs repeatedly to relieve the symptoms. The symptoms are worse in the evening and night when the client is still.
A clinical nurse specialist is asked to present a clinical conference to the student group about brain tumors in children younger than 3 years. The nurse should include which information in the presentation?
- A. Radiation is the treatment of choice.
- B. The most significant symptoms are headache and vomiting.
- C. Head shaving is not required before removal of the brain tumor.
- D. Surgery is not normally performed because of the increased risk of functional deficits.
Correct Answer: B
Rationale: The classic symptoms of children with brain tumors are headaches and vomiting. The treatment of choice is total surgical removal of the tumor. Before surgery, the child's head will be shaved, although every effort is made to shave only as much hair as is necessary. Radiation therapy is avoided in children younger than 3 years because of the toxic side effects on the developing brain, particularly in very young children.
A client diagnosed with urolithiasis is being evaluated to determine the type of calculi that are present. The nurse should plan to keep which item available in the client's room to assist in this process?
- A. A urine strainer
- B. A calorie count sheet
- C. A vital signs graphic sheet
- D. An intake and output record
Correct Answer: A
Rationale: The urine is strained until the stone is passed, obtained, and analyzed. Straining the urine will catch small stones that should be sent to the laboratory for analysis. Once the type of stone is determined, an individualized plan of care for prevention and treatment is developed. Options 2, 3, and 4 are unrelated to the question.