In a patient with decorticate posturing, the nurse observes?

Appeared in: SCTIMST Staff Nurse - 2015 (Set-A)

Explanation

Decorticate posturing is characterized by a specific pattern of involuntary movements indicating severe brain injury.
The classic presentation involves flexion of the upper extremities, with the arms, wrists, and fingers flexed and adducted toward the chest or 'core'.
Simultaneously, the lower extremities are in a state of extension, with the legs stiff and straight, knees extended, and feet in plantar flexion.
This combination of upper body flexion and lower body extension is the defining feature of decorticate posturing.

Option B: This option is incorrect because in decorticate posturing, the lower extremities are extended, not flexed.
Option C: This describes decerebrate posturing, not decorticate posturing. The key differentiator is the position of the arms.
Option D: This is a description of decerebrate posturing, where the elbows are extended.

Clinical Relevance

Nursing practice connection: Use the key finding related to Identification of clinical signs of decorticate posturing to guide bedside assessment, documentation, and the next nursing action.
Recognizing abnormal posturing is a critical nursing skill, as it indicates a severe, acute neurological event that requires immediate intervention.
Decorticate posturing corresponds to a score of 3 on the motor component of the Glasgow Coma Scale (GCS). A change in a patient's GCS score, especially the appearance of posturing, must be reported immediately.
Nursing interventions for a patient with decorticate posturing include protecting the airway (as the patient is unconscious), maintaining head and neck alignment, monitoring vital signs and neurological status closely, and preparing for immediate diagnostic imaging like a CT scan.

How to Approach the Question

First, identify the core concept of the question, which is 'decorticate posturing'.
Recall the definition and key features of this specific type of abnormal posturing. A useful mnemonic is 'de-COR-ticate', where the arms move towards the 'core' of the body.
Visualize the posture: arms are flexed, legs are extended.
Systematically evaluate each option against this mental model.
Option A matches the description perfectly: flexed elbows (upper body) and extended knees (lower body).
Eliminate the other options. Options C and D describe arm extension, which is characteristic of decerebrate posturing. Option B is incorrect because the lower limbs are extended, not flexed.

Concept Tested & Keywords

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E6 Physiology Ganong 27e Vol 1 Part 2 pp. 18-20, 19-21

Practise the full SCTIMST Staff Nurse - 2015 (Set-A)

Attempt every question from this paper in a timed mock, then review the full solution for each one.