When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, how should the nurse report the response?
A.
Localization of pain
B.
Decorticate posturing
C.
Decerebrate posturing
D.
Flexion withdrawal
The correct answer is:
B. Decorticate posturing
Explanation:
- Decorticate posturing (B): This type of posturing is characterized by internal rotation, adduction, and flexion of the arms, and it typically indicates damage to the cerebral hemispheres or the pathways between the brain and the spinal cord.
- Localization of pain (A): This refers to a patient’s ability to locate the source of pain and respond appropriately, which is not described by the posturing observed.
- Decerebrate posturing (C): This is characterized by extension of the arms and legs, with the arms being straight and the hands and feet turned outward, and it indicates damage to the brainstem.
- Flexion withdrawal (D): This is a reflex response where the patient withdraws from a painful stimulus by flexing the affected body part, but it is not specifically described by the posturing in the question.
Thus, the response described is consistent with decorticate posturing