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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Monitoring daily weight can help detect early signs of lithium toxicity, as sudden weight gain may indicate fluid retention, which is a concern with lithium treatment. It is important for clients to monitor their weight regularly to ensure no significant fluctuations occur that could suggest adverse effects⁴.
Choice B reason: Avoiding foods with high tyramine content is not specifically related to lithium therapy. This dietary restriction is more commonly associated with monoamine oxidase inhibitors (MAOIs), a different class of psychiatric medications. Lithium does not interact with tyramine in the same way⁴.
Choice C reason: Limiting daily fluid intake is not recommended for clients taking lithium unless otherwise directed by a healthcare provider. Adequate fluid intake is essential to prevent dehydration, which can increase lithium levels and the risk of toxicity. Clients should maintain a consistent intake of fluids unless they have a condition that requires fluid restriction⁴⁵.
Choice D reason: Following a low sodium diet is not advised for clients on lithium therapy. Lithium is processed in the body similarly to sodium, so if sodium levels are too low, lithium retention may increase, leading to toxicity. Clients should maintain a consistent, adequate intake of sodium to prevent fluctuations in lithium levels⁴.
Correct Answer is C
Explanation
Choice A reason : The plantar reflex, also known as the Babinski sign, is elicited by stroking the lateral aspect of the sole of the foot. A positive response is indicated by dorsiflexion of the big toe and fanning of the other toes. This reflex is normal in infants but may indicate central nervous system damage in adults¹. However, it is not specifically associated with meningeal irritation.
Choice B reason : Kernig's sign is a clinical sign wherein the patient experiences severe stiffness of the hamstrings causing an inability to straighten the leg when the hip is flexed to 90 degrees. This sign can indicate meningeal irritation but is not as early a sign as Brudzinski's sign².
Choice C reason : Brudzinski's sign is one of the most indicative signs of meningeal irritation. When the neck is flexed, there is involuntary flexion of the hips and knees. This reflex is an early sign of meningeal irritation and is considered a critical manifestation in assessing meningitis following head trauma².
Choice D reason : Sunsetting eyes, characterized by the downward deviation of the eyes, is associated with increased intracranial pressure, which can occur in conditions like hydrocephalus. While it may be seen in the context of brain injury, it is not a specific sign of meningeal irritation³.
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