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 C
Explanation
A. "Engage in a vigorous exercise program." This statement may not be suitable for a client with multiple sclerosis experiencing symptoms such as diplopia, dysmetria, and sensory changes. While exercise is beneficial for managing MS symptoms, it should be tailored to the individual's abilities and symptoms.
B. "Plan to relax in a hot tub spa each day." Hot tubs can exacerbate symptoms of multiple sclerosis, particularly heat sensitivity. Therefore, this statement is not appropriate for this client.
C. "Implement a schedule to include periods of rest." Fatigue is a common symptom of multiple sclerosis, and incorporating regular periods of rest into the daily schedule can help manage fatigue and conserve energy.
D. "Wear an eye patch on the right eye at all times." While wearing an eye patch may help alleviate diplopia (double vision), it is not typically recommended for continuous use and should be used under the guidance of an ophthalmologist or healthcare provider.
Correct Answer is ["B","D"]
Explanation
A. Furnish restraints at the bedside: Restraints are not indicated for clients with seizure disorders. In fact, restraints can increase the risk of injury during a seizure and should be avoided.
B. Keep an oxygen setup at the bedside: Oxygen may be necessary to support the client's respiratory function during and after a seizure. Having an oxygen setup readily available can ensure prompt administration if needed.
C. Place the bed in the lowest position: Lowering the bed can help prevent injury if the client
falls out of bed during a seizure. However, it is not always feasible or necessary to lower the bed to the lowest position, especially if the client has mobility limitations or other considerations.
D. Provide a suction setup at the bedside: Suctioning may be necessary to clear the airway and prevent aspiration if the client experiences excessive oral secretions or vomiting during or after a seizure.
E. Elevate the side rails near the head when the client is in bed: Elevating the side rails near the head can help prevent injury if the client thrashes or moves unpredictably during a seizure. However, it is essential to ensure that the client's head and neck remain adequately supported and that the side rails do not restrict access to the client during a seizure.
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