A client has undergone surgery for the creation of burr holes after sustaining head trauma from a fall and is at risk for developing an infection. An early critical manifestation of meningeal irritation for which the nurse assesses the client is :
Plantar reflex
Kernig's sign
Brudzinski's sign
Sunsetting eyes
The Correct Answer is C
Choice A reason : The plantar reflex, also known as the Babinski sign, is elicited by stroking the lateral aspect of the sole of the foot. A positive response is indicated by dorsiflexion of the big toe and fanning of the other toes. This reflex is normal in infants but may indicate central nervous system damage in adults¹. However, it is not specifically associated with meningeal irritation.
Choice B reason : Kernig's sign is a clinical sign wherein the patient experiences severe stiffness of the hamstrings causing an inability to straighten the leg when the hip is flexed to 90 degrees. This sign can indicate meningeal irritation but is not as early a sign as Brudzinski's sign².
Choice C reason : Brudzinski's sign is one of the most indicative signs of meningeal irritation. When the neck is flexed, there is involuntary flexion of the hips and knees. This reflex is an early sign of meningeal irritation and is considered a critical manifestation in assessing meningitis following head trauma².
Choice D reason : Sunsetting eyes, characterized by the downward deviation of the eyes, is associated with increased intracranial pressure, which can occur in conditions like hydrocephalus. While it may be seen in the context of brain injury, it is not a specific sign of meningeal irritation³.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason : Bubbling in the water seal chamber with exhalation can be a normal finding as it indicates that air is being evacuated from the pleural space. However, continuous bubbling may suggest an air leak, which should be evaluated.
Choice B reason : The visibility of the eyelets is not typically a concern unless the tube is dislodged. If the chest tube is functioning properly and the eyelets are meant to be within the chest cavity, their visibility might indicate dislodgement.
Choice C reason : Crepitus, or subcutaneous emphysema, can occur if air leaks into the tissue surrounding the insertion site. This can be a sign of a problem with the chest tube placement or function and should be reported to the provider immediately.
Choice D reason : Movement of the trachea toward the unaffected side, or tracheal deviation, can be a sign of tension pneumothorax, a life-threatening condition that requires immediate attention.
Correct Answer is B
Explanation
Choice A reason : Albuterol is a bronchodilator often used in asthma to relieve symptoms of bronchospasm. While it can help open airways, in a case of anaphylaxis, it does not address the systemic histamine release and is not the first-line treatment¹.
Choice B reason : Epinephrine is the primary treatment for anaphylaxis, which is a severe allergic reaction that can occur after a bee sting. It works rapidly to improve breathing, stimulate the heart, reverse hives, and reduce swelling of the face, lips, and throat¹³. In an emergency situation where a patient is experiencing anaphylactic symptoms such as difficulty breathing and a feeling of a lump in the throat, immediate administration of epinephrine is critical to counteract the reaction.
Choice C reason : The term "high-residual cannula" does not correspond to a recognized medical treatment or device. In the context of anaphylaxis, oxygen may be administered via a high-flow nasal cannula if the patient is experiencing respiratory distress, but this would be secondary to the administration of epinephrine.
Choice D reason : The option "Administer 5 mg prescription of the bee" is nonsensical as it does not refer to a legitimate medical treatment. In the context of bee stings, no medication is prescribed as "prescription of the bee."
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