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 : Anginal pain is commonly triggered by physical exertion or emotional stress, which increases the heart's demand for oxygen. When the narrowed coronary arteries cannot supply enough oxygen-rich blood to the heart muscle, angina occurs³⁷.

Choice B reason : While sitting up may help relieve discomfort for some conditions, anginal pain is typically relieved by resting or taking prescribed medication such as nitroglycerin, which helps to widen the blood vessels and improve blood flow to the heart muscle³⁶.

Choice C reason : This statement is incorrect. Anginal pain does not persist with rest and organic nitrates; these are actually the measures taken to alleviate the pain. Resting decreases the heart's demand for oxygen, and nitrates are effective in relieving anginal pain³.

Choice D reason : Typically, anginal pain does not last longer than a few minutes. If chest pain persists for more than 20 minutes, it may indicate a more serious condition, such as a heart attack, and immediate medical attention is required³.

A. White blood cell count (WBC) B. Calcium C. Absolute neutrophil count (ANC) D. Platelets

Correct Answer is B

Explanation

Choice A reason : In multiple myeloma, the white blood cell count (WBC) is not typically elevated. Multiple myeloma primarily affects plasma cells, a type of white blood cell, but it does not usually result in an increased WBC count. Instead, the disease is characterized by the presence of abnormal plasma cells in the bone marrow, which can crowd out healthy blood cells¹.

Choice B reason : Patients with multiple myeloma often have elevated calcium levels, a condition known as hypercalcemia. This occurs because the cancerous plasma cells produce substances that cause bones to break down at a rate faster than they are made, releasing calcium into the bloodstream. Symptoms of hypercalcemia can include fatigue, weakness, confusion, and increased thirst and urination¹².

Choice C reason : The absolute neutrophil count (ANC) is not typically increased in multiple myeloma. ANC is a measure of the number of neutrophils, a type of white blood cell important for fighting infections. While multiple myeloma can affect overall bone marrow function, it does not specifically cause an increase in ANC.

Choice D reason : Platelet counts are not typically elevated in multiple myeloma. In fact, patients may experience thrombocytopenia, or a low platelet count, due to the overproduction of abnormal plasma cells in the bone marrow, which can interfere with the production of platelets¹.

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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 providing teaching for a client who has a new diagnosis of angina pectoris. Which of the following information should the nurse include about anginal pain?

Correct Answer is A

Explanation

A nurse is reviewing the laboratory results of a client who was admitted with a history of multiple myeloma. The nurse should expect to find an increase in which of the following laboratory values?

Correct Answer is B

Explanation

A nurse is planning care for a client who had a traumatic brain injury and is emerging restlessly from a coma. Which of the following interventions should the nurse include in the plan?

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 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?

A nurse is caring for a client scheduled to receive external radiation to the neck for cancer of the larynx. During a pre-treatment exam, the nurse explains to the client that the most likely side effect would be :

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?

A nurse is caring for a client who has thrombophlebitis and is receiving heparin by continuous IV infusion. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse give?

A nurse is caring for a client who is unable to make any decisions for themselves and needs constant reassurance. The nurse should identify that these are manifestations of which of the following personality disorders?

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?