A client is admitted to the hospital with suspected meningitis.

Which assessment finding should alert the nurse to perform a Kernig's sign test?

Fever

Headache

Nuchal rigidity

Photophobia

Answer and Explanation

The Correct Answer is C

Nuchal rigidity

Rationale: Nuchal rigidity, or stiffness of the neck, is a classic sign of meningitis and indicates inflammation of the meninges, the membranes that cover the brain and spinal cord. Kernig's sign is a test that involves flexing the client's hip and knee at 90 degrees and then attempting to straighten the leg. A positive Kernig's sign is when the client experiences pain or resistance in the hamstring muscles, indicating meningeal irritation.

Incorrect options:

A) Fever - This is a nonspecific sign of infection and inflammation and does not indicate meningitis specifically.

B) Headache - This is a common symptom of meningitis, due to the increased intracranial pressure caused by inflammation of the meninges. However, it is not a specific sign that warrants performing a Kernig's sign test.

D) Photophobia - This is a common symptom of meningitis, due to the sensitivity of the optic nerve to light caused by inflammation of the meninges. However, it is not a specific sign that warrants performing a Kernig's sign test.

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Correct Answer is C

Explanation

"I will avoid foods that are high in calcium."

Rationale: Hydrochlorothiazide is a thiazide diuretic that lowers blood pressure by increasing urine output and reducing fluid volume. However, it also causes increased excretion of potassium and magnesium, and decreased excretion of calcium and uric acid. Therefore, clients taking hydrochlorothiazide should eat more foods that are rich in potassium and magnesium, such as bananas, oranges, potatoes, spinach, nuts, and seeds; limit their intake of sodium and fluids to prevent fluid retention and edema; avoid foods that are high in uric acid, such as organ meats, shellfish, and alcohol; and monitor their serum calcium levels regularly. There is no need to avoid foods that are high in calcium, as hydrochlorothiazide does not increase calcium excretion.

Incorrect options:

A) "I will eat more foods that are rich in potassium." - This is a correct statement, as hydrochlorothiazide causes increased potassium excretion and can lead to hypokalemia if not supplemented.

B) "I will limit my intake of sodium and fluids." - This is a correct statement, as sodium and fluids can cause fluid retention and edema, which can increase blood pressure and counteract the effects of hydrochlorothiazide.

D) "I will drink alcohol in moderation." - This is a correct statement, as alcohol can increase uric acid levels and cause gout attacks in clients taking hydrochlorothiazide. Alcohol can also lower blood pressure and increase the risk of orthostatic hypotension.

A. The type and amount of dressing used B. The location and size of the wound C. The appearance and odor of the wound D. All of the above

Correct Answer is D

Explanation

All of the above

Rationale: The nurse should document all aspects of wound care, including the type and amount of dressing used, the location and size of the wound, and the appearance and odor of the wound. This information helps to monitor the healing process, evaluate the effectiveness of interventions, and identify any signs of infection or complications.

Incorrect options:

A) The type and amount of dressing used - This is an important information to document, but not the only one.

B) The location and size of the wound - This is an important information to document, but not the only one.

C) The appearance and odor of the wound - This is an important information to document, but not the only one.

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A client is admitted to the hospital with suspected meningitis. Which assessment finding should alert the nurse to perform a Kernig's sign test?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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A client is admitted to the hospital with suspected meningitis.

Which assessment finding should alert the nurse to perform a Kernig's sign test?