Ati rn 402 med surg proctored exam
An acute care nurse receives a shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client?
Explanation & Rationale
A. Decorticate posturing is characterized by arms flexed at the elbows with wrists and fingers bent inward toward the chest, indicating damage to the cerebral hemispheres or corticospinal tract. B. Grimacing and leg movement with neck flexion describe a positive Brudzinski’s sign, related to meningeal irritation, not posturing. C. Inability to extend the leg with hip flexion causing pain describes a positive Kernig’s sign, also related to meningeal irritation. D. Arms extended and rigid with palms turned outward describe decerebrate posturing, indicating more severe brainstem injury.
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