The nurse is planning to assess an adult patient with a ...

[nramada]

The nurse is planning to assess an adult patient with a neurological problem for abnormal posturing. For what postures should the nurse specifically assess?
 
  Select all that apply.
  1. decorticate
  2. decerebrate
  3. circumduction
  4. festinating
  5. nystagmus

Question 2

The patient has lower motor neuron injuries. What type of reflexes should the nurse expect to assess in this patient?
 
  1. decreased
  2. increased
  3. normal
  4. exaggerated

[dawsa925]

Answer to Question 1

Correct Answer: 1, 2
In decorticate posturing, the upper arms are close to the sides; the elbows, wrists, and fingers are flexed; the legs are extended with internal rotation; and the feet are plantar flexed. In decerebrate posturing, the neck is extended; the jaw is clenched; the arms are pronated, extended, and close to the sides; the legs are extended straight out; and the feet are plantar flexed. Festinating describes a gait abnormality, and circumduction refers to the circular movement of a limb. Nystagmus is the term for involuntary eye movements seen in stroke patients.

Answer to Question 2

Correct Answer: 1
The finding of abnormally decreased reflexes points to disorders or diseases involving lower motor neuron impairment. The patient's reflexes will not be increased, normal, or exaggerated.