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 C

Explanation

A. Deep purple erythema

This suggests bruising or possible hematoma formation, which is concerning but may not be immediately life-threatening.

B. Facial nerve deficits

This indicates nerve injury, which is serious but may not be immediately life-threatening.

C. Dysphonia or dysphagia

Dysphonia (difficulty speaking) or dysphagia (difficulty swallowing) are signs of airway compromise or injury to structures involved in breathing and swallowing. This requires immediate attention.

D. Heart rate of 100 and blood pressure of 96/68

These vital signs indicate tachycardia and borderline hypotension, which are concerning, but the airway compromise (option C) is more immediately life-threatening.

A. Causative agent and duration of exposure B. Depth of burn C. Anatomical location of burns on the body D. Total Body Surface Area (TBSA) percentage E. Time of day burn occurred

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

Explanation

A. Causative agent and duration of exposure – Chemical, electrical, or thermal burns differ in severity.

B. Depth of burn – Superficial, partial-thickness, and full-thickness burns determine severity.

C. Anatomical location – Burns over joints, face, or perineum have higher morbidity.

D. Total Body Surface Area (TBSA) percentage – Used to estimate fluid resuscitation needs (e.g., Parkland formula).

E. Time of day burn occurred – Time does not affect burn severity.

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

Explanation

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