Assessment (Neuro) Flashcards
The nurse is assessing the motor function of an unconscious client. The nurse should plan to use which technique to test the client’s peripheral response to pain?
a. sternal rub
b. nail bed pressure
c. pressure on the orbital rim
d. squeezing of the sternocleidomastoid muscle
b
(Motor testing in the unconscious client can be done only by testing response to painful stimuli. Nail bed pressure tests a basic peripheral response. Cerebral responses to pain are tested using a sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.)
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.
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 flexion is generalized, it does not indicate localization of pain or flexion withdrawal.
