A client is brought to the emergency department due to vomiting, fever, and a severe headache. The physician suspects meningitis; then assesses the client for meningeal irritation and spinal nerve root inflammation. The nurse documents a positive Kernig's sign when:
The client's forearm spasms when a blood pressure cuff is inflated on the upper arm.
The client complains of pain when his knee is extended with his hip flexed.
The client feels pain in the calf when his foot is dorsiflexed.
The client has a stiff neck when the neck is flexed towards the chest.
The Correct Answer is B
Choice A rationale: This is a positive Trousseau's sign, which indicates hypocalcemia or tetany. It is not related to meningitis or meningeal irritation.
Choice B rationale: Kernig's sign is indicated when there is resistance and pain with knee extension and hip flexion, suggesting meningeal irritation.
Choice C rationale: This is a positive Homan's sign, which indicates deep vein thrombosis or phlebitis. It is not related to meningitis or meningeal irritation.
Choice D rationale: This is a sign of nuchal rigidity, which indicates meningeal irritation, but it is not specific to Kernig's sign. Nuchal rigidity can also be caused by other conditions such as cervical arthritis or muscle spasm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Peptic ulcer disease doesn't typically present with ecchymosis around the umbilicus (Cullen's sign) or significantly elevated amylase and lipase levels.
Choice B rationale: Gastroenteritis is less likely given the specific symptoms, physical exam findings, and laboratory results indicating pancreatic involvement.
Choice C rationale: Acute pancreatitis fits the clinical picture with epigastric pain after heavy alcohol use, persistent nausea/vomiting, tenderness, and elevated amylase and lipase levels.
Choice D rationale: Diverticulitis typically presents with symptoms more localized to the lower abdomen and doesn't cause the characteristic findings seen in this scenario.
Correct Answer is C
Explanation
Choice A rationale: A client with nausea, vomiting, and abdominal pain may have gastroenteritis, food poisoning, or appendicitis, which are not directly related to the eyes.
Choice B rationale: A client with chest tightness and heartburn may have gastroesophageal reflux disease (GERD), angina, or myocardial infarction (MI), which are also not associated with the eyes.
Choice C rationale: A client with facial drooping and left-sided weakness may have a stroke, which is a medical emergency that requires immediate attention. An eye examination can help detect signs of stroke, such as pupil asymmetry, visual field defects, or eye movement abnormalities. A stroke can cause permanent brain damage or death if not treated promptly.
Choice D rationale: A client with fatigue, fever, and productive cough may have a respiratory infection, such as pneumonia or tuberculosis, which are unlikely to affect the eyes unless there is a systemic complication.
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