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: This question is not relevant to BPH, as erectile dysfunction is not a common complication of this condition. Erectile dysfunction can have other causes, such as cardiovascular disease, diabetes, medications, psychological factors, or aging.
Choice B rationale: This question is not relevant to BPH, as penile discharge is not a symptom of this condition. Penile discharge can indicate an infection, such as sexually transmitted diseases, urinary tract infections, or prostatitis.
Choice C rationale: BPH is a condition that causes enlargement of the prostate gland, which can obstruct the flow of urine and cause symptoms such as difficulty in starting or stopping urination, weak or intermittent stream, dribbling, and incomplete bladder emptying. Asking about the force of the urinary stream can help assess the severity of BPH and the need for treatment.
Choice D rationale: This question is not relevant to BPH, as sexual function is not directly affected by this condition. However, some men with BPH may experience reduced libido or satisfaction due to urinary symptoms or psychological distress.
Correct Answer is A
Explanation
Choice A rationale: This statement could indicate that the client is receiving too much dose of the medication, which can cause hyperthyroidism. Hyperthyroidism is a condition where the thyroid gland produces too much thyroid hormone, which can speed up the body's metabolism and cause symptoms such as tremors, nervousness, weight loss, increased heart rate, and heat intolerance.
Choice B rationale: More frequent bowel movements could be a normal effect of the medication, as levothyroxine can improve constipation that is often associated with hypothyroidism.
Choice C rationale: The ability to enjoy cold weather might suggest improved tolerance to cold, which would align with normalized thyroid function.
Choice D rationale: This could be a sign of improved well-being and quality of life due to the medication, as levothyroxine can improve fatigue and depression that are often associated with hypothyroidism.
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