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Rationale 4: Patient report will not provide as much information as needed for this assessment.Global Rationale: Cognitive Level: Applying
Client Need: Physiological IntegrityClient Need Sub: Physiological AdaptationNursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 20-2Question 20Type: MCSAThe nurse recognizes that which assessment observation of a comatose patient has the greatest implications?1. Both arms are extended and adducted, with the palms facing down.2. Fasciculational twitching occurs in the small muscle groups of both arms.3. Muscles of the entire upper extremities are flaccid bilaterally.4. Arms, wrist, and fingers are flexed and adducted.Correct Answer: Rationale 1: This description is characteristic of decerebrate posturing, which indicates severe brain damage.Rationale 2: Fasciculational twitching is involuntary, arising from the spontaneous discharge of a bundle of skeletal muscle fibers, and is usually benign.Rationale 3: This description is characteristic of paralysis. The implications of another finding are more serious.Rationale 4: This description is characteristic of decorticate posturing. The implications of another finding are more serious.1Global Rationale: Cognitive Level: AnalyzingClient Need: Physiological IntegrityClient Need Sub: Physiological AdaptationNursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 20-5Question 21Type: MCSAThe nurse recognizes which observation as a positive Babinski sign?