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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale
Administering sodium polystyrene sulfonate helps to lower potassium levels by exchanging sodium ions for potassium ions in the intestines. However, it is not the first intervention because it takes time to work and does not address the immediate risk of cardiac arrhythmias caused by hyperkalemia.
Choice B rationale
Monitoring the client’s cardiac rhythm is the first intervention because hyperkalemia can cause life-threatening cardiac arrhythmias. Continuous cardiac monitoring allows for the early detection and treatment of these arrhythmias, which is crucial for the client’s safety.
Choice C rationale
Restricting dietary potassium intake is an important long-term management strategy for hyperkalemia, especially in clients with chronic kidney disease. However, it does not address the immediate risk of cardiac arrhythmias and is not the first intervention.
Choice D rationale
Preparing the client for hemodialysis is a definitive treatment for hyperkalemia, especially in clients with chronic kidney disease. However, it is not the first intervention because it takes time to arrange and initiate dialysis. Immediate cardiac monitoring is necessary to manage the acute risk of arrhythmias.

A. A hemorrhagic brain attack is more common than an ischemic brain attack. B. A thrombolytic drug will cause the peripheral and central reflexes to become hyper-reactive. C. A hemorrhagic brain attack requires immediate intervention to prevent further damage. D. An ischemic brain attack is less severe than a hemorrhagic brain attack.

Correct Answer is C

Explanation

Choice A rationale
A hemorrhagic brain attack (stroke) is less common than an ischemic brain attack. Ischemic strokes account for the majority of strokes.
Choice B rationale
Thrombolytic drugs are used to treat ischemic strokes, not hemorrhagic strokes. They do not cause hyper-reactive reflexes.
Choice C rationale
A hemorrhagic brain attack requires immediate intervention to prevent further damage. Hemorrhagic strokes involve bleeding in the brain, which can rapidly worsen and cause severe damage.
Choice D rationale
An ischemic brain attack is not necessarily less severe than a hemorrhagic brain attack. Both types of strokes are serious, but hemorrhagic strokes often require more urgent intervention due to the risk of ongoing bleeding.

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A nurse is assessing a client with suspected meningitis. Which of the following signs would be most indicative of meningitis?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with chronic kidney disease (CKD) who presents with hyperkalemia. Which of the following interventions should the nurse implement first?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

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A nurse is assessing a client with suspected meningitis.

Which of the following signs would be most indicative of meningitis?