A nurse is caring for a client who has cirrhosis of the liver. Which of the following actions should the nurse take?

A. Homan's sign: Homan’s sign is assessed by dorsiflexing the foot to check for calf pain and is used to evaluate for deep vein thrombosis. It is not relevant for diagnosing or assessing meningitis.

B. Trousseau's sign: Trousseau’s sign involves inflating a blood pressure cuff to elicit carpal spasm and is used to assess for hypocalcemia. It is unrelated to meningitis assessment.

C. Brudzinski's sign: Brudzinski’s sign is assessed by flexing the client’s neck; involuntary hip and knee flexion indicates meningeal irritation. This is a classic and important clinical sign in clients with meningitis.

D. Chvostek's sign: Chvostek’s sign is elicited by tapping the facial nerve to assess for hypocalcemia. It is not associated with meningitis assessment and is not relevant in this context.

Rationale for correct choices

• Shortness of breath: The client’s dyspnea indicates impaired oxygenation and potential progression of pneumonia or respiratory compromise. Rapid recognition is essential to prevent hypoxemia or respiratory failure. Persistent shortness of breath warrants immediate interventions such as supplemental oxygen, monitoring, and notifying the provider.

• Productive cough with yellow sputum: The sputum color and productivity suggest a bacterial respiratory infection, which is confirmed by the chest x-ray result (pneumonia) and elevated WBC count. This requires immediate treatment with antibiotics.

• Diminished lung sounds with crackles: Diminished breath sounds and crackles suggest alveolar consolidation or fluid accumulation in the lungs, consistent with pneumonia. These findings indicate impaired gas exchange and increased work of breathing. Prompt assessment ensures early intervention and prevents deterioration.

• Pleuritic chest pain rated 6/10: Moderate chest pain on inspiration can indicate inflammation of the pleura secondary to pneumonia or early complications such as empyema. Pain may limit deep breathing and coughing, increasing the risk of atelectasis and further respiratory compromise. Follow-up ensures pain management and effective pulmonary hygiene.

Rationale for Incorrect Findings

• Nausea without vomiting: While the client reports nausea, it is mild and not associated with dehydration or electrolyte disturbances at this time. It should be monitored but does not require immediate intervention.

• Able to move all extremities and oriented: Neurological status is intact, which is reassuring. No deficits are noted, and immediate follow-up is not required.

• Skin is moist, pedal pulses +2: Perfusion appears adequate. Vital signs and circulation findings do not indicate acute compromise needing urgent intervention.

• Bowel sounds normoactive, last bowel movement this morning, no difficulty urinating: Gastrointestinal and urinary functions are stable. These findings do not require immediate follow-up.