{"id":138709,"date":"2024-09-16T07:07:34","date_gmt":"2024-09-16T07:07:34","guid":{"rendered":"https:\/\/learnexams.com\/blog\/?p=138709"},"modified":"2024-09-16T07:07:36","modified_gmt":"2024-09-16T07:07:36","slug":"an-acute-care-nurse-receives-shift-report-for-a-client-who-has-increased-intracranial-pressure","status":"publish","type":"post","link":"https:\/\/www.learnexams.com\/blog\/2024\/09\/16\/an-acute-care-nurse-receives-shift-report-for-a-client-who-has-increased-intracranial-pressure\/","title":{"rendered":"An acute care nurse receives shift report for a client who has increased intracranial pressure"},"content":{"rendered":"\n<p>An acute care nurse receives 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?<\/p>\n\n\n\n<p>A.<br>Extension of the arms<\/p>\n\n\n\n<p>B.<br>External rotation of the lower extremities<\/p>\n\n\n\n<p>C.<br>Pronation of the hands<\/p>\n\n\n\n<p>D.<br>Plantar flexion of the legs<\/p>\n\n\n\n<p><mark style=\"background-color:rgba(0, 0, 0, 0)\" class=\"has-inline-color has-ast-global-color-6-color\"><strong>The correct answer and Explanation is :<\/strong><\/mark><\/p>\n\n\n\n<p>The correct answer is <strong>C. Pronation of the hands<\/strong>.<\/p>\n\n\n\n<p><strong>Explanation:<\/strong><\/p>\n\n\n\n<p>Decorticate posturing is a type of abnormal flexor response that can be seen in patients with severe brain damage, often due to increased intracranial pressure or other neurological conditions. This posture is characterized by the following key features:<\/p>\n\n\n\n<ol class=\"wp-block-list\">\n<li><strong>Flexion of the arms:<\/strong> In decorticate posturing, the patient\u2019s arms are flexed at the elbows and held close to the body. The hands are usually in a pronated position (palms facing downward) or flexed.<\/li>\n\n\n\n<li><strong>Extension of the legs:<\/strong> The legs are typically extended and internally rotated. This is different from decerebrate posturing, where the arms are extended and the legs may also be extended, with the feet often in plantar flexion.<\/li>\n\n\n\n<li><strong>Pronation of the hands:<\/strong> In decorticate posturing, the hands may be seen in a pronated position due to the flexion at the elbows. This contrasts with decerebrate posturing, where the hands may be more extended or held in an abnormal outward position.<\/li>\n<\/ol>\n\n\n\n<p><strong>Why other options are not correct:<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>A. Extension of the arms:<\/strong> This would be indicative of decerebrate posturing rather than decorticate posturing. Decerebrate posturing involves extension of the arms, whereas decorticate posturing involves flexion of the arms.<\/li>\n\n\n\n<li><strong>B. External rotation of the lower extremities:<\/strong> This is not typically associated with decorticate posturing. The lower extremities in decorticate posturing are usually extended and internally rotated, not externally rotated.<\/li>\n\n\n\n<li><strong>D. Plantar flexion of the legs:<\/strong> Plantar flexion of the feet is more commonly associated with decerebrate posturing, where the legs are extended and the feet may point downward. In decorticate posturing, the feet are usually in a neutral or slightly dorsiflexed position.<\/li>\n<\/ul>\n\n\n\n<p>Decorticate posturing indicates significant neurological impairment and is an important clinical sign to assess in patients with elevated intracranial pressure or severe brain injury.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>An acute care nurse receives 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? A.Extension of the arms B.External rotation of the lower extremities C.Pronation of the hands D.Plantar [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[25],"tags":[],"class_list":["post-138709","post","type-post","status-publish","format-standard","hentry","category-exams-certification"],"_links":{"self":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/138709","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/comments?post=138709"}],"version-history":[{"count":0,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/138709\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/media?parent=138709"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/categories?post=138709"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/tags?post=138709"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}