A nurse assesses a client and notes the client's position as indicated in the illustration below:

How should the nurse document this finding?

Question

A nurse assesses a client and notes the client's position as indicated in the illustration below:

How should the nurse document this finding?

Quizplus · Accepted Answer

The client is demonstrating decorticate posturing,which is seen with interruption in the corticospinal pathway.This finding is abnormal and is a sign that the client's condition has deteriorated.The physician,the charge nurse,and other health care team members should be notified immediately of this change in status.Decerebrate posturing consists of external rotation and extension of the extremities.Hyperreflexes present as increased reflex responses.Spinal cord degeneration presents frequently with pain and discomfort.

A Nurse Assesses a Client and Notes the Client's Position