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 ["A","C","D"]

Explanation

A. Weber test: The Weber test is used to assess hearing by placing a vibrating tuning fork on the center of the forehead. It helps evaluate lateralization of sound and can indicate whether hearing loss is conductive or sensorineural. This test is pertinent for assessing CN VIII, which is responsible for hearing.
B. Magazine: This option is not relevant to the assessment of CN VIII. A magazine is not used in evaluating hearing or vestibular function. The appropriate assessments for CN VIII focus on hearing and balance.
C. Rinne test: The Rinne test involves placing a vibrating tuning fork on the mastoid bone and then near the ear canal to compare air conduction (AC) and bone conduction (BC) of sound. This test helps differentiate between conductive and sensorineural hearing loss and is directly related to assessing CN VIII.
D. Whispered voice test: This test involves the nurse whispering numbers or words while occluding one ear and assessing the client's ability to hear and repeat them. It is a simple way to assess hearing ability and thus evaluates the function of CN VIII.

A. Peripheral Pulses B. Skin temperature C. Pitting Edema D. Capillary refill

Correct Answer is C

Explanation

Rationale:
A) Peripheral Pulses: Peripheral pulses are assessed by palpating the pulse points, such as the radial or dorsalis pedis pulse, to evaluate the strength and regularity of the pulse. This assessment is not related to pressing the skin and observing it for indentation.
B) Skin Temperature: Skin temperature is assessed by palpating the skin with the back of the hand or fingers to detect warmth or coolness. This method does not involve pressing with the thumb and assessing for indentation.
C) Pitting Edema: Pitting edema is assessed by applying pressure to the skin over a bony area, such as the tibia or ankle, and then observing the skin's response after releasing the pressure. The presence of a pit or indentation that remains after the pressure is removed indicates pitting edema, which is a sign of fluid retention.
D) Capillary Refill: Capillary refill is assessed by pressing down on the nail bed or the skin and then observing how quickly the color returns after releasing the pressure. This test measures peripheral circulation and is different from the assessment for pitting edema.

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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

How would the nurse assess CN VIII Acoustic, vestibulocochlear: Select all that Apply

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

Explanation

While performing an assessment the nurse presses the client's arm with the tip of her thumb, holds for a few seconds and releases. The nurse observes the client as shown. What is the nurse assessing?

Correct Answer is C

Explanation

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