Nokea
Which of the following describes decerebrate posturing?
- A. Internal rotation and adduction of arms with the excess, wrists, and fingers.
- B. Back hunched with the position of all four extremities with supination of arms and plantar flexion of feet.
- C. Supination of arms, dorsiflexion of the feet.
- D. Back arched, rigid extension of all four extremities.
Correct Answer: D
Rationale: Decerebrate posturing involves rigid extension of all extremities with arched back, indicating severe brain stem dysfunction. The other options describe decorticate posturing or incorrect combinations of movements.
You may also like to solve these questions
The nurse in the perioperative area is preparing a client for surgery and notices that the client looks sad. The client says, 'I'm scared of having cancer. It's so horrible and I brought it on myself. I should have quit smoking years ago.' What would be the nurse's best response to the client?
- A. It's okay to be scared. What is it about cancer that you're afraid of?'
- B. It's normal to be scared. I would be, too. We'll help you through it.'
- C. Don't be so hard on yourself. You don't know if your smoking caused the cancer.'
- D. Do you feel guilty because you smoked?'
Correct Answer: A
Rationale: Acknowledging fear and exploring specific concerns ('What is it about cancer that you're afraid of?') validates emotions and opens communication. Other responses dismiss feelings, speculate on causation, or focus on guilt, which are less therapeutic.
Which of the following systems is not blocked by spinal anesthesia?
- A. The sympathetic nervous system.
- B. The sensory system.
- C. The parasympathetic nervous system.
- D. The motor system.
Correct Answer: C
Rationale: Spinal anesthesia blocks sensory, motor, and sympathetic systems by affecting nerve roots. The parasympathetic system, mediated by cranial and sacral nerves, is not typically blocked.
A client in the PACU after spinal anesthesia reports a severe headache when sitting up. The nurse suspects:
- A. Dehydration.
- B. Post-dural puncture headache.
- C. Hypertension.
- D. Migraine exacerbation.
Correct Answer: B
Rationale: A severe headache worsened by sitting up after spinal anesthesia is characteristic of a post-dural puncture headache due to cerebrospinal fluid leakage. This requires prompt management, such as hydration or an epidural blood patch.
Which of the following dietary measures would be useful in preventing esophageal reflux?
- A. Eating small, frequent meals.
- B. Increasing fluid intake.
- C. Avoiding air swallowing with meals.
- D. Adding a bedtime snack to the dietary plan.
Correct Answer: A
Rationale: Small, frequent meals reduce gastric distention and lower the risk of reflux compared to large meals. The other options are less effective or may worsen symptoms.
The nurse is monitoring a client after an above-the-knee amputation and notes that blood has saturated through the client and the dressing. The nurse should immediately:
- A. Apply a tourniquet
- B. Assess vital signs
- C. Call the physician
- D. Elevate the surgical extremity with a large pillow
Correct Answer: C
Rationale: Blood saturating the dressing post-amputation suggests significant bleeding, a potential emergency. The nurse should immediately call the physician for evaluation and intervention. Applying a tourniquet is extreme and requires an order, assessing vital signs is secondary, and elevating with a pillow may not address the bleeding source.