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.
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Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: The signs and symptoms of urinary catheter obstruction include hematuria with clots, bladder spasms, and a feeling of urinary urgency. The nurse should increase the rate of the continuous bladder irrigation to flush out the clots and relieve the obstruction. The nurse should also monitor the client's vital signs, fluid balance, and pain level. The other options are not consistent with the client's presentation.
Choice B rationale: Shock would cause hypotension, tachycardia, and decreased urine output.
Choice C rationale: Hyponatremia would cause confusion, weakness, and seizures.
Choice D rationale: Urinary tract infection would cause fever, chills, and foul-smelling urine.
Correct Answer is D
Explanation
Choice A rationale: Used in the management of hepatic encephalopathy by reducing the production of ammonia in the gut.
Choice B rationale: Often prescribed to reduce ammonia levels in hepatic encephalopathy by promoting bowel movements and aiding ammonia excretion. Choice C rationale: Typically used in managing ascites by reducing fluid retention and treating edema.
Choice D rationale: This medication can potentially worsen hepatic encephalopathy due to its sedative effects and impact on mental function. It's crucial to clarify its use in a patient with hepatic encephalopathy.
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