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: Performing active range of motion exercises may not be safe or appropriate immediately following a hemorrhagic stroke.
Choice B rationale: Maintaining the head of bed flat or at a 30-degree position might be used for ischemic strokes but not necessarily for hemorrhagic strokes.
Choice C rationale: Teaching measures to avoid the Valsalva maneuver (straining during activities like defecation) helps prevent sudden increases in intracranial pressure, which can be detrimental after a hemorrhagic stroke.
Choice D rationale: Monitoring for Battle's sign (bruising behind the ears associated with basilar skull fracture) is not relevant in the care of a hemorrhagic stroke.
Correct Answer is A
Explanation
Choice A rationale: These lab findings, particularly concentrated urine (high specific gravity) and hyponatremia, are consistent with SIADH, where excessive ADH secretion leads to water retention and dilutional hyponatremia.
Choice B rationale: While it can affect sodium levels, Cushing's syndrome typically results in hypernatremia or normal sodium levels rather than hyponatremia.
Choice C rationale: Usually presents with hyponatremia but not specifically with high urine specific gravity or hematocrit.
Choice D rationale: DI is associated with high serum sodium and low urine specific gravity due to excessive excretion of dilute urine.
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