1. A patient with a severe head injury is admitted to the ICU. The nurse

suspects that the patient has damage to the brainstem based on which of the

following findings?

a) Loss of corneal reflex

b) Decorticate posturing

c) Dilated and fixed pupils *

d) Cheyne-Stokes breathing

Rationale: Dilated and fixed pupils indicate damage to the cranial nerve III,

which originates from the midbrain, a part of the brainstem. Loss of corneal

reflex is due to damage to the cranial nerve V, which originates from the pons,

another part of the brainstem, but it is not as specific as pupil changes.

Decorticate posturing and Cheyne-Stokes breathing are signs of damage to the

cerebral hemispheres or the diencephalon, not the brainstem.

2. A patient with a subarachnoid hemorrhage has a Glasgow Coma Scale score

of 8. The nurse performs a neurologic assessment and finds that the patient

has no response to painful stimuli, except for extension and internal rotation

of the arms and legs. The nurse documents this as:

a) Decerebrate posturing *

b) Decorticate posturing

c) Flaccid paralysis

d) Spastic paralysis

Rationale: Decerebrate posturing is characterized by extension and internal

rotation of the arms and legs in response to painful stimuli. It indicates