When preparing to test a client for meningeal irritation, what would the nurse do first?

Check for a Babinski reflex

Position the client prone

Ensure no injury to the cervical spine

Check for evidence of fever and chills

Answer and Explanation

The Correct Answer is C

A.   The Babinski reflex is a test used to assess the integrity of the corticospinal tract and is particularly useful in evaluating neurological function in infants and adults with neurological conditions. However, it is not specifically related to testing for meningeal irritation.
B.   Positioning the client prone (lying on their stomach) is not typically used when testing for meningeal irritation. The tests for meningeal irritation, such as the Brudzinski sign and Kernig sign, are performed with the client in a supine (lying on their back) position to accurately assess reactions to neck flexion and leg movements.
C.   Before performing tests for meningeal irritation, such as neck flexion, it is important to ensure that the client does not have an injury to the cervical spine. If there is a possibility of cervical spine injury, performing neck flexion could exacerbate the injury. Ensuring that there is no cervical spine injury helps to avoid causing harm and ensures a safe examination.
D.   While fever and chills can be associated with infections that may cause meningeal irritation (such as meningitis), checking for these symptoms is not the first step in assessing meningeal irritation itself.

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Correct Answer is A

Explanation

A. Flight of ideas is characterized by a rapid and continuous flow of thoughts where the individual frequently shifts topics, often making it difficult to follow their conversation. This is commonly observed in conditions like mania or hypomania, often seen in bipolar disorder.
B. Confabulation involves fabricating or inventing stories or information to fill in gaps in memory. It is often seen in conditions affecting memory or cognition, such as Korsakoff’s syndrome or certain types of dementia.
C. Depression typically involves symptoms such as low mood, decreased energy, and lack of interest in activities, rather than rapid speech or topic shifts. The client’s accelerated pace of speech and jumping from topic to topic do not align with the characteristics of depression.
D. Schizophrenia is a broad term for a range of symptoms, including hallucinations, delusions, disorganized thinking, and impaired social functioning. While disorganized thinking can be a symptom of schizophrenia, the specific behavior described (accelerated speech and jumping topics) more specifically indicates flight of ideas, which is not exclusive to schizophrenia.

A. Coma B. Stupor C. Lethargy D. Obtunded

Correct Answer is D

Explanation

A. Coma is a state of profound unconsciousness where the patient cannot be awakened and does not respond to any external stimuli. The patient is completely unresponsive, with no eye opening or verbal responses.
B. Stupor is a state where the patient is almost completely unresponsive and can only be awakened by vigorous or painful stimuli. When aroused, they may only give brief, non-purposeful responses.
C. Lethargy is characterized by drowsiness and decreased alertness. The patient may fall asleep easily but can be awakened and will respond appropriately to stimuli. They might appear sluggish or tired.
D. Obtunded refers to a state where the patient has a reduced level of consciousness and responsiveness. They may be difficult to arouse, respond slowly to stimuli, and have a dulled sense of awareness. They need increased stimulation to achieve a response.

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When preparing to test a client for meningeal irritation, what would the nurse do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is admitting a client to the unit for surgery the next morning. The nurse notes that the client speaks at an accelerated pace and jumps from topic to topic no of which progresses to sensible conversation. What would the nurse document about this client?

Correct Answer is A

Explanation

In the Neuro ICU (intensive care unit) while performing a neurological assessment of the patient the nurse noticed the patient: patient opens eyes, looks at you, responds slowly, and is somewhat confused. What level of consciousness (LOC) is this patient presenting?

Correct Answer is D

Explanation

While conducting an assessment the nurse suspects that a client is making up things in response to specific questions. What behavior is this client demonstrating?

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