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 D
Explanation
Choice A rationale: Dysphagia, substernal burning, and belching are symptoms often associated with hiatal hernia.
Choice B rationale: While substernal burning can be a symptom of stomach-related issues, hiatal hernia is more directly linked to the symptoms described.
Choice C rationale: Schatzki ring might present with dysphagia, but it's less likely given the overall symptoms described.
Choice D rationale: Symptoms of dysphagia and substernal burning can be indicative of a hiatal hernia, especially when considered together.
Correct Answer is ["A","B","C","D","E"]
Explanation
Choice A rationale: This is a condition where the skin of the breast becomes dimpled and resembles an orange peel. It is caused by blockage of the lymphatic vessels by cancer cells or inflammation.
Choice B rationale: This is a condition where the skin of the breast breaks down and forms an open sore. It can be a sign of advanced or inflammatory breast cancer.
Choice C rationale: This is a condition where the nipple becomes inverted or pulled inward. It can be caused by scarring, infection, or cancer in the breast tissue or ducts.
Choice D rationale: These are lymph nodes in the armpit that are enlarged and hard but not painful. They can be a sign of cancer spreading from the breast to the lymphatic system.
Choice E rationale: This is a lump in the breast that can be felt and moved around. It is located at the upper outer quadrant of the right breast, as if looking at a clock face. It can be benign or malignant, depending on its size, shape, consistency, and borders.
Choice F rationale: Dense breast tissue is not an abnormal finding that indicates possible breast cancer. It is a normal variation that makes it harder to detect lumps or
abnormalities on mammograms. Women with dense breasts may need additional screening tests such as ultrasound or MRI.
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