SOLUTIONS AND CORRECT ANSWERS
ALREADY PASSED
◉ Decorticate posturing indicates injury to which structures:
A) Cerebral hemispheres and brainstem
B) Lower spinal cord only
C) Peripheral nerves
D) Cerebellum only. Answer: A) Cerebral hemispheres and
brainstem
◉ Which assessment finding is consistent with decorticate
posturing:
A) Arms extended and pronated, legs extended
B) Arms adducted with elbows and wrists flexed, legs extended
C) Flaccid upper extremities and flexed legs
D) Bilateral plantar flexion. Answer: B) Arms adducted with elbows
and wrists flexed, legs extended
◉ Decerebrate posturing is commonly caused by:
A) Mild cortical irritation
B) Peripheral nerve damage
,C) Severe metabolic disturbance or upper brainstem lesions
D) Isolated sensory impairment. Answer: C) Severe metabolic
disturbance or upper brainstem lesions
◉ Which finding describes decerebrate posturing:
A) Flexion of arms and wrists with leg extension
B) Extension and pronation of arms and legs
C) Bilateral plantar flexion
D) Flaccid paralysis of all extremities. Answer: B) Extension and
pronation of arms and legs
◉ A patient previously demonstrated abnormal flexion but now
demonstrates abnormal extension. The nurse should interpret this
as:
A) Improvement in neurological function
B) Normal variation in response
C) No significant change
D) Possible neurological deterioration. Answer: D) Possible
neurological deterioration
◉ The presence of abnormal flexion on one side and abnormal
extension on the other side of the body is:
A) Impossible
,B) A normal finding
C) Possible
D) Indicative of a negative Babinski reflex. Answer: C) Possible
◉ The Babinski reflex is used to assess for dysfunction of which
system:
A) Lower motor neurons
B) Upper motor neurons
C) Cranial nerves
D) Cerebellar function. Answer: B) Upper motor neurons
◉ How should the Babinski reflex be elicited during assessment:
A) Tap the Achilles tendon
B) Apply nail bed pressure
C) Scratch the sole of the foot from heel to great toe with a blunt
object
D) Flex the knee and extend the ankle. Answer: C) Scratch the sole of
the foot from heel to great toe with a blunt object
◉ Which response represents a normal (negative) Babinski reflex in
an adult:
A) Dorsiflexion of the big toe with fanning
B) Extension and pronation of the arms
, C) Plantar flexion of the toes
D) Absence of any toe movement. Answer: C) Plantar flexion of the
toes
◉ Which finding indicates a positive Babinski reflex:
A) Downward curling of all toes
B) Upward movement of the big toe with fanning of other toes
C) Flexion of the knee
D) Extension of both arms. Answer: B) Upward movement of the big
toe with fanning of other toes
◉ Which action assesses Cranial Nerve I function:
A) Ask the patient to identify a familiar smell with eyes closed
B) Shine a light into the pupil
C) Ask the patient to shrug shoulders
D) Assess tongue movement. Answer: A) Ask the patient to identify a
familiar smell with eyes closed
◉ Which assessment evaluates Cranial Nerve II:
A) Assess facial symmetry
B) Test visual acuity
C) Ask the patient to clench teeth