Question

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

a) Decerebrate posturing
b) Normal posturing
c) Decorticate posturing
d) Flaccid paralysis

Answer 1

The child with a head injury is experiencing decerebrate posturing, characterized by abnormal flexion of the upper extremities and extension of the lower extremities.

Step-by-step explanation:

The abnormal flexion of the upper extremities and extension of the lower extremities observed in the child with a head injury is known as decerebrate posturing. In decerebrate posturing, the upper limbs are extended and adducted, while the lower limbs are extended and internally rotated. This is indicative of damage to the brainstem, specifically the midbrain or upper pons. It is important for the nurse to document this finding accurately to assist in the diagnosis and treatment of the child.