Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
61. A client with a brain tumor has been unresponsive to verbal commands and is showing signs of abnormal motor responses. Which motor change should indicate to the nurse that a critical change in the client's condition has occurred?
. Abnormal flexion of the upper extremities.
. Extreme extension of arms and legs.
. Diminished response to painful stimuli.
. Disappearance of the Babinski response.
Test-Taking Tip
Remember that a response to pain is desired.
Content Area: Adult Health, Neurological; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
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Answer 1 is incorrect because decorticate posturing may result from painful stimulation. Answer 2 is incorrect because decerebrate posturing, a poor prognostic sign, may occur with painful stimuli. Answer 3 is correct because the lack of response to noxious stimuli signals a deepening coma. Answer 4 is incorrect because the Babinski reflex is not normally present in adults. If present, it is a pathologic response.