A nurse is assessing a client who has meningitis and notes that when passively flexing the client's neck, there is an involuntary flexion of both legs. Which of the following conditions is the client displaying?

Bradykinesia

Brudzinski's sign

Kernig's sign

Nuchal rigidity

Answer and Explanation

The Correct Answer is B

Choice A reason : Bradykinesia refers to the slowness of movement and is commonly associated with Parkinson's disease, not meningitis. It is characterized by a gradual loss of spontaneous movement and can affect the ability to initiate and continue movements¹.

Choice B reason : Brudzinski's sign is a clinical sign that suggests meningitis when neck flexion causes reflex flexion of the hips and knees. It occurs due to meningeal irritation caused by spinal cord movement or nerves against the meninges¹. This sign is considered positive when passive flexion of the neck results in reflex flexion of the hips and knees, indicating meningeal irritation².

Choice C reason : Kernig's sign is another clinical sign used to evaluate for meningitis. It involves extending and straightening one knee while the individual lies on their back with their hips and knees bent at a 90-degree angle. A positive Kernig’s sign indicates pain or resistance when the leg is extended, which suggests meningitis³. However, it is not the condition described in the scenario.

Choice D reason : Nuchal rigidity is an inability to flex the neck forward due to rigidity of the neck muscles. While it is a sign of meningitis, it does not involve the involuntary flexion of the legs as described in the scenario. Nuchal rigidity is typically assessed by attempting to flex the patient's neck forward while they are in a supine position⁴.

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Correct Answer is C

Explanation

Choice A reason : Decreasing the client's carbohydrate intake is not typically a priority intervention for cirrhosis and ascites. While managing overall nutrition is important, carbohydrates are a necessary component of a balanced diet and provide essential energy¹.

Choice B reason : Increasing the client's saturated fat intake is not recommended in cirrhosis and ascites. Saturated fats can contribute to fatty liver disease and worsen liver function. A diet low in saturated fats and high in omega-3 fatty acids is generally advised¹.

Choice C reason : Decreasing the client's fluid intake is a key intervention for managing ascites in cirrhosis. Ascites is the accumulation of fluid in the peritoneal cavity, and reducing fluid intake can help manage this condition. The goal is to prevent further fluid accumulation and reduce the risk of complications such as spontaneous bacterial peritonitis¹².

Choice D reason : Increasing the client's sodium intake is not advised for cirrhosis and ascites. Sodium can cause the body to retain water, exacerbating fluid accumulation in the abdomen. A low-sodium diet is typically recommended to help control ascites¹.

A. Delegate the NG tube placement to a more experienced nurse. B. Make a referral to Social Services related to body image disturbance. C. Seek the client's spouse for consent to the procedure. D. Document the client's wishes and notify the physician.

Correct Answer is D

Explanation

Choice A reason : Delegating the NG tube placement to a more experienced nurse does not address the client's refusal of the procedure. The nurse must respect the client's autonomy and decision-making rights.

Choice B reason : While a referral to Social Services may be appropriate in some cases, it does not directly address the immediate concern of the client's refusal of the NG tube placement.

Choice C reason : Seeking consent from the client's spouse is not appropriate as the client is competent and has the right to refuse treatment. The client's autonomy must be respected.

Choice D reason : Documenting the client's wishes and notifying the physician is the correct action. The nurse must respect the client's right to refuse treatment and communicate this decision to the physician so that alternative management can be considered.

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A nurse is assessing a client who has meningitis and notes that when passively flexing the client's neck, there is an involuntary flexion of both legs. Which of the following conditions is the client displaying?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has cirrhosis and ascites. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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