A nurse is assessing a client who has meningitis and notes 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
Kernig's sign
Nuchal rigidity
Brudzinski's sign
The Correct Answer is D
A. Bradykinesia: Bradykinesia refers to slowness of movement and is commonly associated with Parkinson's disease. It is not typically assessed through neck flexion in the context of meningitis.
B. Kernig's sign: Kernig's sign is assessed by flexing the patient's hip and knee and then attempting to extend the knee. Resistance or pain during knee extension suggests meningeal irritation, but it does not involve the involuntary flexion of the legs.
C. Nuchal rigidity: Nuchal rigidity refers to stiffness and pain in the neck and inability to flex the neck forward due to inflammation of the meninges. While it is related to meningitis, it does not involve involuntary flexion of the legs.
D. Brudzinski's sign: Brudzinski's sign is a physical exam finding where passive flexion of the neck results in involuntary flexion of the hips and knees. It is a classic sign of meningeal irritation, often seen in meningitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Restlessness: Restlessness is a common early sign of increased intracranial pressure (ICP) in clients with traumatic brain injury. It can result from discomfort, confusion, or agitation due to pressure on the brain.
B. Amnesia: Amnesia, or memory loss, can occur with traumatic brain injury but is not specifically indicative of increased intracranial pressure.
C. Tachycardia: Tachycardia may occur in response to various factors such as pain, stress, or fever, but it is not a specific indicator of increased intracranial pressure.
D. Hypotension: Hypotension (low blood pressure) is not typically associated with increased intracranial pressure. In fact, hypertension (high blood pressure) may be a compensatory response to maintain cerebral perfusion pressure in the setting of elevated ICP.
Correct Answer is B
Explanation
A. Catheterize for residual urine after voiding: While catheterization for residual urine may be necessary in some cases, it is not the most appropriate long-term solution for managing a neurogenic reflexic bladder. It does not promote patient independence or long-term bladder health.
B. Instruct the patient how to self-catheterize: Self-catheterization empowers the patient to manage their bladder function independently and reduces the risk of urinary tract infections
associated with indwelling catheters. It is the preferred method for managing neurogenic bladder in patients with spinal cord injury.
C. Assist the patient to the toilet every 2 hours: While assisting the patient to the toilet at regular intervals may help prevent urinary accidents, it does not address the underlying issue of neurogenic bladder or promote long-term bladder management.
D. Teach the patient to use the Credé method: The Credé method involves applying manual pressure to the bladder to promote voiding. While it may be used in some situations, it is not the preferred method for managing neurogenic bladder, especially in patients with spinal cord injury.
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