Which of the following describes the correct procedure for testing for Kernig's sign?
Rotate the neck to one side while observing the eyes moving to the opposite side.
Passively elevate the leg with extended knee while observing for pain, resistance, or flexion.
Stroke the lateral aspect of the sole of the patient's foot and observe for dorsiflexion of the big toe.
Passively flex the patient's neck forward and observe for hip and knee flexion.
The Correct Answer is B
Choice A rationale: Rotating the neck to one side while observing the eyes moving to the opposite side is a procedure for testing for oculocephalic reflex or doll's eye
phenomenon, which indicates brainstem function.
Choice B rationale: This is the correct answer. Kernig's sign is a clinical sign that indicates meningitis, which is an inflammation of the membranes that cover the brain and spinal cord. To test for Kernig's sign, the nurse should flex the patient's hip to 90 degrees and then attempt to extend the knee. A positive Kernig's sign is when the patient
experiences pain in the lower back or hamstring, resists knee extension, or involuntarily flexes the opposite leg.
Choice C rationale: Stroking the lateral aspect of the sole of the patient's foot and observing for dorsiflexion of the big toe is a procedure for testing for Babinski's sign, which indicates upper motor neuron lesion or damage.
Choice D rationale: Passively flexing the patient's neck forward and observing for hip and knee flexion is a procedure for testing for Brudzinski's sign, which also indicates meningitis.
 |
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Redness briefly after removing the appliance might be common due to increased blood flow but does not necessarily indicate an issue.
Choice B rationale: A deep red-purple stoma color can suggest impaired blood supply to the stoma and requires immediate attention.
Choice C rationale: The consistency of output from the colostomy may vary based on the site and type of colostomy and might not necessarily be concerning.
Choice D rationale: The length of the stoma can vary and usually depends on the type of colostomy, and 1/2 inch above the abdomen is within an acceptable range.
Correct Answer is A
Explanation
Choice A rationale: Gloves should be worn during direct contact with the client's skin. This is a standard precaution that applies to all clients, but especially to those with infectious diseases that can be transmitted through contact. Secondary syphilis is highly contagious and can be spread through direct contact with the skin lesions or mucous
membranes of an infected person.
Choice B rationale: This is incorrect because secondary syphilis requires more than standard precautions to prevent transmission.
Choice C rationale: This is incorrect because handwashing is a basic component of standard precautions and is not sufficient to prevent the spread of syphilis.
Choice D rationale: This is incorrect because a mask is not necessary for contact precautions, unless the client has respiratory symptoms or is undergoing aerosol- generating procedures.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today