Difficulty: Medium
Average Score: 94%
Simulated
While providing care to a client with a head injury, the nurse notes that a client exhibits this posture (refer to figure). What should the nurse document that the client is exhibiting?
Correct answer
B
Rationale
Decortication is abnormal posturing seen in the client with lesions that interrupt the corticospinal pathways. In this posturing, the client's arms, wrists, and fingers are flexed with internal rotation and plantar flexion of the feet and legs extended. Flaccidity indicates weak, soft, and flabby muscles that lack normal muscle tone. Decerebration is abnormal posturing and rigidity characterized by extension of the arms and legs, pronation of the arms, plantar flexion, and opisthotonos. Decerebration is usually associated with dysfunction in the brainstem area. Rigidity indicates hardness, stiffness, or inflexibility. Decerebrate posturing is associated with rigidity.