Question

The nurse is monitoring a child with a head injury. On data collection, the nurse notes abnormal flexion of the upper extremities and extension of the lower extremities. The nurse documents that the child is experiencing which?

a. Decerebrate posturing
b. Decorticate posturing
c. Opisthotonus
d. Flaccid paralysis

Answer 1

The child with abnormal flexion in the upper extremities and extension in the lower extremities is experiencing decorticate posturing.

Step-by-step explanation:

The nurse is observing a child with a head injury who is displaying abnormal flexion of the upper extremities and extension of the lower extremities. This type of posturing is referred to as decorticate posturing, where the upper limbs are flexed or bent inward on the chest and the hands are clenched into fists, while the lower limbs are extended and turned outward. The scenario described does not align with decerebrate posturing, opisthotonus, or flaccid paralysis. Decerebrate posturing involves extension of both the upper and lower extremities, opisthotonus is characterized by severe hyperextension of the back due to muscle spasm, and flaccid paralysis presents as a lack of both muscle tone and reflexes.