A client is brought to the emergency department due to vomiting, fever, and a severe headache. The physician suspects meningitis; then assesses the client for meningeal irritation and spinal nerve root inflammation. The nurse documents a positive Kernig's sign when:
The client's forearm spasms when a blood pressure cuff is inflated on the upper arm.
The client complains of pain when his knee is extended with his hip flexed.
The client feels pain in the calf when his foot is dorsiflexed.
The client has a stiff neck when the neck is flexed towards the chest.
The Correct Answer is B
Choice A rationale: This is a positive Trousseau's sign, which indicates hypocalcemia or tetany. It is not related to meningitis or meningeal irritation.
Choice B rationale: Kernig's sign is indicated when there is resistance and pain with knee extension and hip flexion, suggesting meningeal irritation.
Choice C rationale: This is a positive Homan's sign, which indicates deep vein thrombosis or phlebitis. It is not related to meningitis or meningeal irritation.
Choice D rationale: This is a sign of nuchal rigidity, which indicates meningeal irritation, but it is not specific to Kernig's sign. Nuchal rigidity can also be caused by other conditions such as cervical arthritis or muscle spasm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: This statement could indicate that the client is receiving too much dose of the medication, which can cause hyperthyroidism. Hyperthyroidism is a condition where the thyroid gland produces too much thyroid hormone, which can speed up the body's metabolism and cause symptoms such as tremors, nervousness, weight loss, increased heart rate, and heat intolerance.
Choice B rationale: More frequent bowel movements could be a normal effect of the medication, as levothyroxine can improve constipation that is often associated with hypothyroidism.
Choice C rationale: The ability to enjoy cold weather might suggest improved tolerance to cold, which would align with normalized thyroid function.
Choice D rationale: This could be a sign of improved well-being and quality of life due to the medication, as levothyroxine can improve fatigue and depression that are often associated with hypothyroidism.
Correct Answer is D
Explanation
Choice A rationale: This is not relevant to the current condition of the patient and does not support a diagnosis of renal calculi.
Choice B rationale: This is a sign of upper gastrointestinal bleeding, which can have many causes such as peptic ulcer, gastritis or esophageal varices. It is not related to renal calculi or urinary tract problems.
Choice C rationale: Renal calculi usually causes pain which usually radiates anteriorly to the lower abdomen, groin, labia, testicles or the perineum depending on the location of the stone.
Choice D rationale: This is a sign of hematuria, which is blood in the urine caused by the passage of renal calculi (kidney stones) through the urinary tract. Hematuria can also cause the urine to appear dark or brown in color.
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