A nurse is assessing a client with suspected meningitis.
Which of the following signs would be most indicative of meningitis?
Positive Brudzinski’s sign.
Positive Babinski’s sign.
Positive Romberg’s sign.
Positive Murphy’s sign.
The Correct Answer is A
Choice A rationale
A positive Brudzinski’s sign is indicative of meningitis. It involves involuntary lifting of the legs when the neck is flexed, suggesting meningeal irritation.
Choice B rationale
A positive Babinski’s sign indicates central nervous system pathology but is not specific to meningitis. It involves dorsiflexion of the big toe when the sole of the foot is stimulated.
Choice C rationale
A positive Romberg’s sign indicates issues with proprioception and balance but is not specific to meningitis. It involves swaying or falling when standing with eyes closed.
Choice D rationale
A positive Murphy’s sign indicates gallbladder inflammation (cholecystitis) and is not related to meningitis. It involves pain on palpation of the right upper quadrant during inspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Administering vitamin B12 to increase RBC size is not appropriate in this scenario. The elevated MCV indicates macrocytic anemia, which is often due to vitamin B12 deficiency. The goal is to restore normal RBC maturation, not to increase RBC size.
Choice B rationale
Administering vitamin B12 to restore normal RBC maturation is the appropriate action. The elevated MCV indicates macrocytic anemia, which is often due to vitamin B12 deficiency.
Administering vitamin B12 will help restore normal RBC maturation and correct the anemia.
Choice C rationale
Administering medication to decrease RBC size is not appropriate in this scenario. The elevated MCV indicates macrocytic anemia, which is often due to vitamin B12 deficiency. The goal is to restore normal RBC maturation, not to decrease RBC size.
Choice D rationale
Administering iron to increase the formation of hemoglobin molecules is not appropriate in this scenario. The elevated MCV indicates macrocytic anemia, which is often due to vitamin B12 deficiency. Iron supplementation is typically used for microcytic anemia, not macrocytic anemia.
Correct Answer is A
Explanation
Choice A rationale
Administering antipyretic medication as prescribed is a priority intervention for a client with a body temperature of 38°C (100.4°F). Antipyretics help reduce fever and provide comfort to the patient. They work by inhibiting the production of prostaglandins, which are involved in the fever response.
Choice B rationale
Encouraging fluid intake to prevent dehydration is also important, but it is not the priority intervention. Adequate hydration helps maintain fluid balance and supports the body’s ability to regulate temperature.
Choice C rationale
Monitoring vital signs every 4 hours is essential for assessing the patient’s condition, but it is not an intervention that directly addresses the fever. It helps track the patient’s response to treatment and detect any changes in their condition.
Choice D rationale
Applying a cooling blanket to reduce fever can be effective, but it is typically used when antipyretic medications are not sufficient or contraindicated. Cooling measures help lower body temperature through conduction and evaporation.
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