A nurse is caring for a client who has meningitis. Which of the following assessments should the nurse perform?
Homans' sign
Trousseau's sign
Brudzinski's sign
Chvostek's sign
The Correct Answer is C
A. Homan's sign: Homan’s sign is assessed by dorsiflexing the foot to check for calf pain and is used to evaluate for deep vein thrombosis. It is not relevant for diagnosing or assessing meningitis.
B. Trousseau's sign: Trousseau’s sign involves inflating a blood pressure cuff to elicit carpal spasm and is used to assess for hypocalcemia. It is unrelated to meningitis assessment.
C. Brudzinski's sign: Brudzinski’s sign is assessed by flexing the client’s neck; involuntary hip and knee flexion indicates meningeal irritation. This is a classic and important clinical sign in clients with meningitis.
D. Chvostek's sign: Chvostek’s sign is elicited by tapping the facial nerve to assess for hypocalcemia. It is not associated with meningitis assessment and is not relevant in this context.
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Related Questions
Correct Answer is D
Explanation
A. Wear an N95 respirator: An N95 respirator is required for airborne precautions, such as with tuberculosis. Neutropenic clients are not at risk for transmitting infections but are highly susceptible to acquiring them, so an N95 is not necessary.
B. Insert an indwelling urinary catheter to monitor urinary output: Invasive devices increase the risk of infection in neutropenic clients. Catheterization should be avoided unless absolutely necessary, as it can introduce pathogens.
C. Monitor the client's vital signs every 8 hr: Neutropenic clients require more frequent monitoring to detect early signs of infection. Waiting 8 hours between assessments may delay recognition of sepsis or other complications.
D. Use a dedicated stethoscope: Using a dedicated stethoscope and other equipment for the neutropenic client helps prevent the transmission of pathogens from other patients. This is a key component of neutropenic (protective) precautions to reduce infection risk.
Correct Answer is C
Explanation
A. Keep the head of the client's bed at a 15° angle: Elevating the head of the bed only slightly is insufficient for optimal lung expansion. A higher elevation, usually 30–45°, is recommended to improve ventilation and ease breathing during an exacerbation.
B. Place the client on bedrest for 24 hr: Prolonged bedrest can decrease lung expansion and increase the risk of mucus retention. Encouraging activity as tolerated helps maintain respiratory function and prevents complications.
C. Instruct the client to increase fluid intake to 2.5 L per day: Increased fluid intake helps thin secretions, making them easier to expectorate. This is a key intervention in managing an acute exacerbation of chronic bronchitis to improve airway clearance.
D. Encourage the client to perform deep-breathing exercises every 6 hr: Deep-breathing exercises are beneficial, but they should be performed more frequently than every 6 hours, often hourly or as tolerated, to effectively prevent atelectasis and improve oxygenation.
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