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1. A patient with a severe head injury is admitted to the ICU. The nurse
suspects that the patient has damage to the brainstem based on which of the
following findings?
a) Loss of corneal reflex
b) Decorticate posturing
c) Dilated and fixed pupils *
d) Cheyne-Stokes breathing
Rationale: Dilated and fixed pupils indicate damage to the cranial nerve III,
which originates from the midbrain, a part of the brainstem. Loss of corneal
reflex is due to damage to the cranial nerve V, which originates from the pons,
another part of the brainstem, but it is not as specific as pupil changes.
Decorticate posturing and Cheyne-Stokes breathing are signs of damage to the
cerebral hemispheres or the diencephalon, not the brainstem.
2. A patient with a subarachnoid hemorrhage has a Glasgow Coma Scale score
of 8. The nurse performs a neurologic assessment and finds that the patient
has no response to painful stimuli, except for extension and internal rotation
of the arms and legs. The nurse documents this as:
a) Decerebrate posturing *
b) Decorticate posturing
c) Flaccid paralysis
d) Spastic paralysis
Rationale: Decerebrate posturing is characterized by extension and internal
rotation of the arms and legs in response to painful stimuli. It indicatesÂÂ
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