When preparing to test a client for meningeal irritation, which of the following would be most important for the nurse to do first?

Assess for Kerning and Burzinski signs.

Ensure no injury to the cervical spine

Check for a Babinski reflex

Position the client prone

Answer and Explanation

The Correct Answer is B

A) Assess for Kernig and Brudzinski signs: Kernig and Brudzinski signs are used to test for meningeal irritation, often associated with conditions like meningitis. However, these tests should not be performed if there is a risk of spinal injury, as they could potentially exacerbate any existing cervical spine injury.
B) Ensure no injury to the cervical spine: Before performing tests that involve neck movements, such as those for meningeal irritation, it is crucial to ensure that there is no existing cervical spine injury. Performing such tests on a client with a cervical spine injury could lead to further harm. Therefore, checking for cervical spine stability and injury is the most important initial step.
C) Check for a Babinski reflex: The Babinski reflex is used to assess neurological function but is not specifically related to detecting meningeal irritation. It is not the immediate priority when evaluating for possible cervical spine injury.

D) Position the client prone: Positioning the client prone is not relevant for assessing meningeal irritation and may not be appropriate depending on the client’s condition. The focus should be on ensuring the client's safety and stability before performing specific physical tests.

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

Explanation

A. BMI of 20: While a BMI of 20 is on the lower end of the normal range, it does not necessarily indicate a high risk for pressure injuries. Extreme low BMI may pose a risk, but a BMI of 20 alone is not a definitive factor in increasing pressure injury risk compared to the other listed conditions.
B. Peripheral neuropathy: Peripheral neuropathy impairs sensation in the skin, which reduces the client’s ability to feel pressure, pain, or discomfort. This diminished sensory perception increases the risk of developing pressure injuries as the client might not be aware of or respond to pressure-related issues.
C. Immobility: Immobility, or limited mobility, significantly raises the risk of pressure injuries because it prevents the client from frequently changing positions. Prolonged pressure on specific body areas can impede blood flow and lead to skin breakdown.
D. Hypoperfusion: Hypoperfusion indicates reduced blood flow to tissues, which can contribute to tissue ischemia and increase the risk of pressure injuries. Inadequate blood flow prevents adequate oxygen and nutrient delivery to the skin, making it more susceptible to damage.

A. Egophony B. normal voice transmission. C. Air filled lungs D. Bronchophony

Correct Answer is A

Explanation

A. Egophony: Egophony is a type of abnormal voice sound transmission where the letter "E" is heard as an "A" when auscultated through a stethoscope. This can indicate underlying lung pathology, such as consolidation or infection, that alters the way sounds are transmitted through the lung tissue.
B. Normal voice transmission: Normal voice transmission would involve hearing the letter "E" clearly and accurately as the patient says it, without distortion. The presence of an "A" sound indicates an abnormal finding, not a normal one.
C. Air-filled lungs: Air-filled lungs typically transmit voice sounds clearly and normally. If the sound changes to an "A," this suggests a pathology that alters sound transmission, rather than indicating simply air-filled lungs.
D. Bronchophony: Bronchophony refers to the increased clarity of spoken sounds heard through the stethoscope over areas of lung consolidation, but it does not specifically describe the transformation of the letter "E" to "A." The specific change in sound transmission described here is characteristic of egophony.

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When preparing to test a client for meningeal irritation, which of the following would be most important for the nurse to do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a pressure injury risk assessment for a client. Which of the following findings increases the client's risk of a pressure injury?

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

Explanation

During a respiratory physical assessment, the nurse directs the patient to say and repeat the letter E for the transmitted voice sounds assessment. The nurse by auscultation hears the letter A instead of E. This is known as:

Correct Answer is A

Explanation

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