A nurse is assessing a client who has meningitis and notes that when passively flexing the client's neck, there is an involuntary flexion of both legs. Which of the following conditions is the client displaying?

Bradykinesia

Brudzinski's sign

Kernig's sign

Nuchal rigidity

Answer and Explanation

The Correct Answer is B

Choice A reason : Bradykinesia refers to the slowness of movement and is commonly associated with Parkinson's disease, not meningitis. It is characterized by a gradual loss of spontaneous movement and can affect the ability to initiate and continue movements¹.

Choice B reason : Brudzinski's sign is a clinical sign that suggests meningitis when neck flexion causes reflex flexion of the hips and knees. It occurs due to meningeal irritation caused by spinal cord movement or nerves against the meninges¹. This sign is considered positive when passive flexion of the neck results in reflex flexion of the hips and knees, indicating meningeal irritation².

Choice C reason : Kernig's sign is another clinical sign used to evaluate for meningitis. It involves extending and straightening one knee while the individual lies on their back with their hips and knees bent at a 90-degree angle. A positive Kernig’s sign indicates pain or resistance when the leg is extended, which suggests meningitis³. However, it is not the condition described in the scenario.

Choice D reason : Nuchal rigidity is an inability to flex the neck forward due to rigidity of the neck muscles. While it is a sign of meningitis, it does not involve the involuntary flexion of the legs as described in the scenario. Nuchal rigidity is typically assessed by attempting to flex the patient's neck forward while they are in a supine position⁴.

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Correct Answer is ["A","B","C","E","F"]

Explanation

Choice A reason : Morphine sulfate is used intravenously in acute heart failure with pulmonary edema because it can reduce preload and afterload, thereby decreasing the work of the heart and improving breathing.

Choice B reason : Administering oxygen is crucial for a client with pulmonary edema to improve oxygenation and relieve symptoms of hypoxia.

Choice C reason : Transporting the client to the coronary care unit is appropriate for continuous monitoring and management of acute heart failure and pulmonary edema.

Choice D reason : While placing the client in a high Fowler's position is recommended to ease breathing, the low Fowler's side-lying position is not typically indicated for pulmonary edema. Therefore, this choice is incorrect.

Choice E reason : Inserting a Foley catheter can help monitor urine output, especially important when administering diuretics like furosemide, and manage fluid status.

Choice F reason : Administering furosemide (Lasix), a diuretic, helps to reduce fluid overload and relieve pulmonary congestion in clients with heart failure and pulmonary edema.

A. The provider will be coming to explain the situation. B. "I reported the incident to my supervisor who decided to contact the authorities." C. "As a nurse, I am required by law to report suspected child abuse." D. "I am unable to discuss this, but I can contact my supervisor to speak with you."

Correct Answer is C

Explanation

Choice A reason : While it is true that a healthcare provider may come to explain the situation, this response does not directly address the parent's concern about the reason for the nurse's action. It is important for the nurse to communicate clearly and directly about their responsibilities and the actions they have taken.

Choice B reason : This response indicates that the nurse has taken action by reporting to a supervisor, but it does not clarify the nurse's legal obligation to report suspected child abuse. It is essential for nurses to understand and communicate their role as mandated reporters to ensure transparency and trust in the healthcare setting¹.

Choice C reason : This is the most appropriate response because it directly addresses the parent's question and explains the nurse's legal responsibility. Nurses are mandated reporters and are legally required to report any suspicions of child abuse to protect the child's welfare. This response is clear, direct, and upholds the nurse's professional and legal obligations¹³.

Choice D reason : While contacting a supervisor may be part of the protocol, this response does not provide the parent with an explanation for the nurse's action. It is important for the nurse to explain their legal duty to report suspected child abuse, which is the primary reason for their action.

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A nurse is assessing a client who has meningitis and notes that when passively flexing the client's neck, there is an involuntary flexion of both legs. Which of the following conditions is the client displaying?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","E","F"]

Explanation

A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate?

Correct Answer is C

Explanation

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