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 A
Explanation
Choice A rationale: Post-surgery, there's a risk of lymphedema in the affected arm, so avoiding procedures like venipuncture or blood pressure measurements in the left arm helps prevent complications.
Choice B rationale: Obtaining a permanent breast prosthesis is a consideration post- recovery but not an immediate priority upon return to the surgical unit.
Choice C rationale: Patient-controlled analgesia instructions are important but don't specifically address immediate care after mastectomy.
Choice D rationale: Insisting that the patient examine the surgical incision might not be appropriate upon return to the unit, and it's typically done by healthcare professionals during dressing changes.
Correct Answer is B
Explanation
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.
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