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 A

Explanation

Choice A reason : The immediate safety of the client is the nurse's primary concern. Assessing the risk for immediate harm is crucial to prevent further abuse and to ensure the client's well-being. This involves evaluating the severity of the situation and the potential for future harm¹.

Choice B reason : While referring the client to a community support group is important for long-term support, it is not the immediate priority when a client reports abuse.

Choice C reason : Implementing a safety plan is a critical step, but it follows the initial assessment of immediate risk. The safety plan will be part of the ongoing support and intervention for the client.

Choice D reason : Instructing the client on how to leave the relationship is an important aspect of empowering the client; however, it is not the first action to take before assessing immediate risk and ensuring the client's safety.

A. Implement seizure precautions. B. Place the client in a semi-Fowler's position. C. Admit the client to a private room. D. Measure head circumference every shift.

Correct Answer is D

Explanation

Choice A reason : Implementing seizure precautions is necessary for a child with bacterial meningitis due to the increased risk of seizures associated with the condition.

Choice B reason : Placing the client in a semi-Fowler's position can help reduce intracranial pressure and facilitate breathing, which is beneficial for a child with meningitis.

Choice C reason : Admitting the client to a private room is important to prevent the spread of infection and provide a quiet environment to reduce the risk of seizures and other complications.

Choice D reason : Measuring head circumference every shift is not typically necessary for a 6-year-old child with bacterial meningitis. This intervention is more relevant for infants whose skull bones have not yet fused.

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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 caring for a client who has reported experiencing abuse at home. Which of the following actions should be a priority for the nurse?

Correct Answer is A

Explanation

A nurse is planning care for a 6-year-old child who has bacterial meningitis. Which of the following nursing interventions is unnecessary in the client's plan of care?

Correct Answer is D

Explanation

A client has been diagnosed with heart failure. One of the main overall objectives of the management of heart failure is which of the following?

A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect?

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first?

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?

A nurse is assessing a client who has meningitis and notes that when passively flexing the client's neck, there is an involuntary flexion of both legs. Which of the following conditions is the client displaying?

A nurse is providing teaching to a client who has a new prescription for tamoxifen to treat breast cancer. The nurse should include that which of the following is an adverse effect of this medication?

A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestations should indicate to the nurse that the client is experiencing an increase in intracranial pressure (ICP)? (Select all that apply.)