Author Question: When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and ... (Read 39 times)

fnuegbu · **on:** Jun 25, 2018

When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, the nurse reports the response as

a. flexion withdrawal.
b. localization of pain.
c. decorticate posturing.
d. decerebrate posturing.

Question 2

Which assessments will the nurse make to monitor a patient's cerebellar function (select all that apply)?

a. Assess for graphesthesia.
b. Observe arm swing with gait.
c. Perform the finger-to-nose test.
d. Check ability to push against resistance.
e. Determine ability to sense heat and cold.

Dinolord · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: C
Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flex-ion is generalized, it does not indicate localization of pain or flexion withdrawal.

Answer to Question 2

ANS: B, C
The cerebellum is responsible for coordination and is assessed by looking at the patient's gait and the finger-to-nose test. The other assessments will be used for other parts of the neurologic assessment.