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 C
Explanation
Choice A reason : This statement is misleading. While heparin does need to reach a therapeutic level to be effective, it does not directly dissolve existing clots. Heparin's primary action is to prevent the formation of new clots and the extension of existing clots by inhibiting certain factors in the coagulation cascade.
Choice B reason : While a pharmacist can provide detailed information about medications, it is the nurse's responsibility to educate and inform the client about the effects of their treatment. Therefore, this response would not be appropriate.
Choice C reason : This is the most accurate response. Heparin works by inhibiting the formation of fibrin, which is essential for clot formation. It does not have the ability to dissolve existing clots but can prevent new ones from forming and existing ones from getting larger.
Choice D reason : Oral medications such as warfarin or direct oral anticoagulants (DOACs) may be used after heparin to maintain anticoagulation; however, they also do not dissolve clots. The body's natural fibrinolytic system is responsible for breaking down clots over time.
Correct Answer is C
Explanation
Choice A reason : White beans do not have a significant interaction with warfarin. They are a good source of protein and fiber and can be included in the diet unless otherwise contraindicated.
Choice B reason : Cantaloupe does not interact significantly with warfarin and can be consumed as part of a balanced diet. It is rich in vitamins and hydration.
Choice C reason : Cabbage contains vitamin K, which can interfere with the effectiveness of warfarin. Vitamin K is essential for blood clotting, and warfarin works by inhibiting the effects of this vitamin. Therefore, patients on warfarin are advised to maintain a consistent intake of vitamin K and avoid sudden increases in foods high in this nutrient.
Choice D reason : Green beans have a moderate amount of vitamin K but are not typically restricted for patients on warfarin. It is important for patients to maintain a consistent intake of vitamin K; thus, they should not make significant changes to their diet without consulting their healthcare provider.
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