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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Expressive aphasia (also known as Broca’s aphasia) is a condition where the individual has difficulty producing speech or writing, despite having relatively intact comprehension and awareness of their
communication difficulties. This condition often results from damage to Broca’s area in the left frontal lobe of the brain
B. Aphonia refers to the loss of voice or the inability to produce vocal sounds. It is typically associated with a physical issue affecting the vocal cords or larynx, such as vocal cord paralysis or severe laryngitis. Aphonia does not necessarily affect comprehension or the ability to understand speech, but rather the ability to produce sound.
C. Receptive aphasia (also known as Wernicke’s aphasia) is characterized by difficulty understanding or processing language, despite fluent speech production. Individuals with receptive aphasia often speak in long sentences that lack meaning or include incorrect or nonsensical words, and they have impaired comprehension
D. Dysphonia refers to difficulty in producing speech due to issues with the voice, such as hoarseness or discomfort, often related to vocal cord problems. While it affects the quality of the voice, it does not necessarily impact the ability to understand language or produce speech in a meaningful way. Dysphonia is not the correct choice for the scenario described.
Correct Answer is C
Explanation
A. Kyphosis is a condition characterized by an excessive outward curvature of the thoracic spine, leading to a hunchbacked appearance. It often results from degenerative diseases, osteoporosis, or other spinal conditions.
B. Lordosis refers to an excessive inward curvature of the lumbar spine, often referred to as "swayback." This condition can be congenital or due to other factors like obesity or pregnancy.
C. Osteoporosis is a bone condition characterized by decreased bone density and strength, leading to an increased risk of fractures. It is particularly common in postmenopausal women due to decreased estrogen levels, which help maintain bone density.
D. Scoliosis is a condition characterized by an abnormal lateral curvature of the spine. It can be congenital, idiopathic, or secondary to other conditions.
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