The nurse is caring for a patient who has a diminished level of consciousness and who is mechanically ventilated.While performing endotracheal suctioning,the patient reaches up in an attempt to grab the suction catheter.What is the best interpretation by the nurse?
A) The patient is exhibiting extension posturing.
B) The patient is exhibiting flexion posturing.
C) The patient is exhibiting purposeful movement.
D) The patient is withdrawing to stimulation.

Question

Quizplus · Accepted Answer

This is a good example of purposeful movement that is sometimes seen in patients with reduced consciousness.Flexion posturing is characterized by rigid flexion and extension of the arms,wrist flexion,and clenched fists.Extension posturing is characterized by rigid extension of arms and legs with plantar extension of the feet.Withdrawing occurs when a patient moves an extremity away from a painful source of stimulation.

The Nurse Is Caring for a Patient Who Has a Diminished