A client has undergone surgery for the creation of burr holes after sustaining head trauma from a fall and is at risk for developing an infection. An early critical manifestation of meningeal irritation for which the nurse assesses the client is :

Plantar reflex

Kernig's sign

Brudzinski's sign

Sunsetting eyes

Answer and Explanation

The Correct Answer is C

Choice A reason : The plantar reflex, also known as the Babinski sign, is elicited by stroking the lateral aspect of the sole of the foot. A positive response is indicated by dorsiflexion of the big toe and fanning of the other toes. This reflex is normal in infants but may indicate central nervous system damage in adults¹. However, it is not specifically associated with meningeal irritation.

Choice B reason : Kernig's sign is a clinical sign wherein the patient experiences severe stiffness of the hamstrings causing an inability to straighten the leg when the hip is flexed to 90 degrees. This sign can indicate meningeal irritation but is not as early a sign as Brudzinski's sign².

Choice C reason : Brudzinski's sign is one of the most indicative signs of meningeal irritation. When the neck is flexed, there is involuntary flexion of the hips and knees. This reflex is an early sign of meningeal irritation and is considered a critical manifestation in assessing meningitis following head trauma².

Choice D reason : Sunsetting eyes, characterized by the downward deviation of the eyes, is associated with increased intracranial pressure, which can occur in conditions like hydrocephalus. While it may be seen in the context of brain injury, it is not a specific sign of meningeal irritation³.

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Correct Answer is D

Explanation

Choice A reason : Ecchymosis of the extremities is not a typical finding associated with common bile duct obstruction. It refers to bruising, which can have many causes unrelated to bile duct issues⁴.

Choice B reason : Straw-colored urine is usually a sign of well-hydrated and healthy individuals. In the case of common bile duct obstruction, the urine may actually become darker due to increased bilirubin levels⁴.

Choice C reason : Tenderness in the left upper abdomen is more commonly associated with issues related to the stomach, spleen, or pancreas, not the common bile duct⁴.

Choice D reason : Clay stools are a classic symptom of common bile duct obstruction. When bile flow is blocked, stools can lose their normal brown color and appear pale or clay-colored due to the absence of bilirubin⁴.

A. Obsessive-Compulsive Disorder B. Schizophrenia C. Generalized Anxiety Disorder D. Anorexia Nervosa E. environment is important when caring for a client with hypomanic episodes. What should the nurse do when caring for clients with this disorder?

Correct Answer is C

Explanation

Choice A reason: Obsessive-Compulsive Disorder (OCD) is characterized by persistent, unwanted thoughts (obsessions) and behaviors (compulsions) that the individual feels the urge to repeat over and over. While OCD is a separate condition that can co-occur with many disorders, it is not commonly associated as a comorbidity with histrionic personality disorder⁴⁵.

Choice B reason: Schizophrenia is a severe mental disorder that affects how a person thinks, feels, and behaves. It is not typically associated with histrionic personality disorder, which is characterized by excessive emotionality and attention-seeking behaviors⁴⁵.

Choice C reason: Generalized Anxiety Disorder (GAD) is a common comorbidity with histrionic personality disorder. Individuals with histrionic personality disorder may experience high levels of anxiety, which can manifest as GAD. This anxiety often relates to fears of rejection or not being the center of attention⁴⁵.

Choice D reason: Anorexia Nervosa is an eating disorder characterized by an abnormally low body weight, intense fear of gaining weight, and a distorted perception of body weight. It is more commonly associated with other conditions, such as obsessive-compulsive and avoidant personality disorders, rather than histrionic personality disorder⁴⁵.

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A client has undergone surgery for the creation of burr holes after sustaining head trauma from a fall and is at risk for developing an infection. An early critical manifestation of meningeal irritation for which the nurse assesses the client is :

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has an obstruction of the common bile duct resulting from chronic cholecystitis. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse identifies that theA nurse is educating a newly licensed nurse about comorbidities associated with cluster B personality disorders. The nurse should identify which of the following disorders as a comorbidity of histrionic personality disorder?

Correct Answer is C

Explanation

A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?

A nurse is preparing a client who is to receive chemotherapy for the treatment of breast cancer. Which of the following actions should the nurse plan to take?

A nurse is teaching a client about the seven warning signs of cancer. Which of the following signs should the nurse include as manifestations of cancer? (Select all that apply.)

A nurse in the emergency department is caring for a client who took three nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now is experiencing a headache. Which of the following statements should the nurse make?

A client has undergone surgery for the creation of burr holes after sustaining head trauma from a fall and is at risk for developing an infection. An early critical manifestation of meningeal irritation for which the nurse assesses the client is :

A nurse in a drug and alcohol detoxification center is planning care for a client who has alcohol use disorder and is currently in withdrawal. Which of the following interventions should the nurse identify as the priority?

A nurse is caring for a client who has heart failure and a potassium level of 2.4 mEq/L. The nurse should identify which of the following medications as contributing to this lab value?

A nurse is caring for a client who has been diagnosed with obsessive-compulsive disorder (OCD) and is constantly picking up after others in the day room. The nurse should recognize that the client uses this behavior to do which of the following?