During an assessment of a 32-year-old patient with a recent head ...

[asmith134]

During an assessment of a 32-year-old patient with a recent head injury, the nurse notices that the patient responds to pain by extending, adducting, and internally rotating his arms. His palms pronate, and his lower extremities extend with
 
  plantar flexion. Which statement concerning these findings is most accurate? This patient's response:
  a.
  Indicates a lesion of the cerebral cortex.
  b.
  Indicates a completely nonfunctional brainstem.
  c.
  Is normal and will go away in 24 to 48 hours.
  d.
  Is a very ominous sign and may indicate brainstem injury.

Question 2

A 32-year-old woman tells the nurse that she has noticed very sudden, jerky movements mainly in her hands and arms. She says, They seem to come and go, primarily when I am trying to do something. I haven't noticed them when I'm sleeping.
 
  This description suggests:
  a.
  Tics.
  b.
  Athetosis.
  c.
  Myoclonus.
  d.
  Chorea.

[shoemake]

Answer to Question 1

ANS: D
These findings are all indicative of decerebrate rigidity, which is a very ominous condition and may indicate a brainstem injury.

Answer to Question 2

ANS: D
Chorea is characterized by sudden, rapid, jerky, purposeless movements that involve the limbs, trunk, or face. Chorea occurs at irregular intervals, and the movements are all accentuated by voluntary actions.