Nokea
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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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.
The nurse has admitted a client diagnosed with gestational hypertension who is in labor. The nurse monitors the client closely for which complication of gestational hypertension?
- A. Seizures
- B. Hallucinations
- C. Placenta previa
- D. Altered respiratory status
Correct Answer: A
Rationale: Gestational hypertension can lead to preeclampsia and eclampsia; therefore, a major complication of gestational hypertension is seizures. Hallucinations, placenta previa, and altered respiratory status are not directly associated with gestational hypertension.
The nurse is caring for a client diagnosed with a herniated lumbar intervertebral disk who is experiencing low back pain. Which position should the nurse place the client in to minimize the pain?
- A. Supine with the knees slightly raised
- B. High Fowler's position with the foot of the bed flat
- C. Semi-Fowler's position with the foot of the bed flat
- D. Semi-Fowler's position with the knees slightly raised
Correct Answer: D
Rationale: Clients with low back pain are often more comfortable in the semi-Fowler's position with the knees raised sufficiently to flex the knees (William's position). This relaxes the muscles of the lower back and relieves pressure on the spinal nerve root. Keeping the bed flat or lying in a supine position with the knees raised would excessively stretch the lower back. Keeping the foot of the bed flat will enhance extension of the spine.
The nurse is caring for a client with a nasogastric tube that is attached to low suction. If the client's HCO3- is 30, which additional value is most likely to be noted in this client?
- A. pH 7.52
- B. pH 7.36
- C. pH 7.25
- D. pH 7.20
Correct Answer: A
Rationale: Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis because of the loss of hydrochloric acid (HCl), an acid secreted in the stomach. This occurs as HCO3 rises above normal. Thus, the loss of hydrogen ions in the HCl results in alkalosis. A pH above 7.45 would be noted.
Which arterial blood gas (ABG) values should the nurse anticipate in the client with a nasogastric tube attached to continuous suction?
- A. pH 7.25, PaCO2 55, HCO3 24
- B. pH 7.30, PaCO2 38, HCO3 20
- C. pH 7.48, PaCO2 30, HCO3 23
- D. pH 7.49, PaCO2 38, HCO3 30
Correct Answer: D
Rationale: Continuous nasogastric suction can lead to metabolic alkalosis due to the loss of gastric acid (hydrochloric acid), which reduces hydrogen ions and increases bicarbonate levels. The ABG values in option 4 (pH 7.49, PaCO2 38, HCO3 30) indicate metabolic alkalosis, with an elevated pH and high bicarbonate level, consistent with this condition. Option 1 suggests respiratory acidosis, option 2 suggests metabolic acidosis, and option 3 suggests respiratory alkalosis, none of which align with the expected acid-base imbalance from nasogastric suction.