The nurse is assessing a client who is unconscious and applies a painful stimulus to the nail beds. The client responds with internal rotation, adduction, and flexion of the arms. Which of the following terms should the nurse use when documenting the findings?
A)Flexion withdrawal
B)Localization of pain
C)Decorticate posturing
D)Decerebrate posturing

Question

Quizplus · Accepted Answer

Internal rotation, adduction, and flexion of the arms in an unconscious client is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is generalized, it does not indicate localization of pain or flexion withdrawal.

The Nurse Is Assessing a Client Who Is Unconscious and Applies