A nurse is assessing a client who has meningitis and notes 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

Kernig's sign

Nuchal rigidity

Brudzinski's sign

Answer and Explanation

The Correct Answer is D

A. Bradykinesia: Bradykinesia refers to slowness of movement and is commonly associated with Parkinson's disease. It is not typically assessed through neck flexion in the context of meningitis.

B. Kernig's sign: Kernig's sign is assessed by flexing the patient's hip and knee and then attempting to extend the knee. Resistance or pain during knee extension suggests meningeal irritation, but it does not involve the involuntary flexion of the legs.

C. Nuchal rigidity: Nuchal rigidity refers to stiffness and pain in the neck and inability to flex the neck forward due to inflammation of the meninges. While it is related to meningitis, it does not involve involuntary flexion of the legs.

D. Brudzinski's sign: Brudzinski's sign is a physical exam finding where passive flexion of the neck results in involuntary flexion of the hips and knees. It is a classic sign of meningeal irritation, often seen in meningitis.

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Correct Answer is B

Explanation

A. Catheterize the patient every 3 to 4 hours: Catheterization may be necessary for urinary retention, which is common in cauda equina syndrome, but it should not be done routinely every 3 to 4 hours. Indwelling catheters increase the risk of urinary tract infections and should be avoided unless necessary.

B. Administer medications to reduce bladder spasm: Bladder spasm is a common complication of cauda equina syndrome and can lead to urinary retention. Medications such as anticholinergics or alpha-adrenergic blockers may be prescribed to reduce bladder spasm and facilitate urine elimination.

C. Assist the patient to ambulate 4 times daily: Ambulation may not be appropriate for a patient with cauda equina syndrome, especially if they have significant motor or sensory deficits. Ambulation should be assessed on an individual basis and may require assistance or adaptive devices.

D. Stabilize the neck when repositioning the patient: Cauda equina syndrome affects the lower spinal cord and does not typically involve the cervical spine. Stabilizing the neck is important in patients with cervical spine injuries but is not directly related to cauda equina syndrome.

A. Hyperthermia B. Weakened gag reflex C. Absence of bowel sounds D. Hypotension E. Polyuria

Correct Answer is ["B","D"]

Explanation

A. Slurred speech: This can be a sign of increased ICP but is not typically considered a late sign. It is more often associated with early or moderate increases in ICP when the brain is starting to experience pressure but is not yet at a critical stage.
B. Bradycardia: This is a late sign of increased ICP and is part of Cushing's triad, which includes bradycardia, irregular respirations, and a widened pulse pressure. Bradycardia occurs as a compensatory mechanism to decrease the cerebral blood flow in response to increased ICP.
C. Hypotension: While changes in blood pressure can be associated with ICP, hypotension is not typically a late sign of increased ICP. In fact, hypertension with a widened pulse pressure would be more indicative of increased ICP as part of Cushing's triad.
D. Nonreactive dilated pupils: This is a late sign of increased ICP and indicates brain stem herniation or compression, which is a medical emergency. The pupils become fixed and dilated as the oculomotor nerve is compressed due to increased pressure.
E. Confusion: Confusion can be an early sign of increased ICP as it indicates changes in mental status. However, it is not specifically a late sign of increased ICP, as it can occur at various stages of pressure changes within the brain.

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

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