The nurse is assessing a client for Brudzinskis sign as part of their neurologic assessment. Which of the following are appropriate actions by the nurse when performing this technique? SELECT ALL THAT APPLY

Bend the client's head toward their chest

Ask the client to extend both arms above their head

Place the client in supine position

The nurse will place a hand behind the client's head

Assist the client to bend their knee 90 degrees

Answer and Explanation

Correct Answer : A,C,D

A. Bend the client’s head toward their chest is correct because Brudzinski’s sign is tested by flexing the client’s neck and observing for an involuntary flexion of the hips and knees, which suggests meningeal irritation.

B. Ask the client to extend both arms above their head is incorrect; this is not part of the test for Brudzinski’s sign.

C. Place the client in a supine position is correct because the test must be done with the client lying flat on their back.

D. The nurse will place a hand behind the client’s head is correct because the nurse gently lifts the client’s head to assess for involuntary hip and knee flexion.

E. Assist the client to bend their knee 90 degrees is incorrect; knee bending is not required for Brudzinski’s sign but is part of Kernig’s sign testing.

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Correct Answer is A

Explanation

A. Stop transfusion, run normal saline is correct because the client is likely experiencing an acute hemolytic transfusion reaction (AHTR), which is life-threatening. The priority is to stop the transfusion immediately and maintain IV access with normal saline to prevent further hemolysis.

B. Administer morphine IV is incorrect because pain management is important, but stopping the transfusion is the immediate priority.

C. Administer epinephrine IM is incorrect because epinephrine is used for anaphylaxis, not hemolytic reactions.

D. Continue to monitor the infusion is incorrect because the transfusion must be stopped immediately to prevent worsening hemolysis.

A. Atropine 1mg IV push B. Epinephrine 1 mg (1:10,000) IV X1 C. Adenosine 6 mg IV push D. Milrinone 50 mcg/kg IV push

Correct Answer is A

Explanation

A. Atropine 1 mg IV push

A C3 spinal cord injury disrupts sympathetic control, causing bradycardia. Atropine is the first-line treatment for symptomatic bradycardia.

B. Epinephrine 1 mg IV

Epinephrine is used for cardiac arrest, not initial management of bradycardia.

C. Adenosine 6 mg IV push

Adenosine is used for supraventricular tachycardia, not bradycardia.

D. Milrinone 50 mcg/kg IV push

Milrinone is an inotrope used in heart failure, not bradycardia.

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The nurse is assessing a client for Brudzinskis sign as part of their neurologic assessment. Which of the following are appropriate actions by the nurse when performing this technique? SELECT ALL THAT APPLY

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Explanation

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