A patient with severe brain injury holds both arms flexed toward the chest and keeps the legs extended. How should the nurse document this response?
Correct answer: A. Decorticate posturing suggesting serious brain dysfunction
- A. Decorticate posturing suggesting serious brain dysfunction
- B. Decerebrate posturing suggesting isolated peripheral nerve damage
- C. Flaccid paralysis suggesting an uncomplicated muscle injury
- D. Typical flexor withdrawal suggesting normal protective movement
Explanation
Flexion of the arms with extension of the legs is decorticate posturing and indicates severe dysfunction above the brainstem. Decerebrate posturing is characterized by extension and outward rotation of the upper limbs and generally indicates more extensive brainstem involvement.
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Covers nursing assessment and management of stroke, epilepsy, meningitis, raised intracranial pressure, head injury, spinal cord disorders, Parkinson disease and multiple sclerosis. Key areas include level of consciousness, pupil responses, motor and sensory findings, seizure precautions and distinguishing upper motor neuron from lower motor neuron signs.
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