A patient is diagnosed with Meningitis. During the physical examination in the supine position, the nurse flexed the patient's neck and the patient flexed his knees and hip while complaining of neck pain. This is known as:

Obturator sign

Brudzinski sign

Phalen sign

Tinel sign

Answer and Explanation

The Correct Answer is B

A.   The obturator sign is used to assess for appendicitis, not meningitis. To perform this test, the patient’s right knee is flexed to 90 degrees, and the nurse rotates the hip internally and externally. Pain during this maneuver can indicate irritation of the obturator muscle, which is associated with inflammation of the appendix.

B.   The Brudzinski sign is a clinical test used to assess meningeal irritation. When the patient’s neck is passively flexed while lying supine, a positive Brudzinski sign is indicated if the patient involuntarily flexes their knees and hips in response to neck pain. This sign is often seen in meningitis as a result of irritation of the meninges.
C.   The Phalen sign is used to diagnose carpal tunnel syndrome. The patient flexes their wrists and holds the position for a period of time to see if symptoms of numbness or tingling appear in the fingers, which would indicate median nerve compression at the wrist. This sign is unrelated to meningitis.
D.   The Tinel sign is also used to diagnose carpal tunnel syndrome and other peripheral nerve issues. It involves tapping on the nerve (such as the median nerve at the wrist) to see if it causes tingling or a “pins and needles” sensation along the nerve’s distribution. Like the Phalen sign, it is not related to meningitis.

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Correct Answer is ["A","B"]

Explanation

A. The verbal response is one of the three components of the Glasgow Coma Scale. It assesses the patient's ability to speak and respond appropriately to questions, indicating their level of consciousness. Responses are scored based on clarity, coherence, and relevance.
B. Motor response is another component of the Glasgow Coma Scale. It evaluates the patient’s ability to move in response to stimuli, including purposeful movements, localizing pain, or abnormal posturing. The motor response helps gauge the patient’s level of consciousness and neurological function.
C. Pupillary response refers to how the pupils react to light and changes in size. While important in neurological assessments, it is not one of the three components of the Glasgow Coma Scale. Pupillary response is assessed separately from the GCS but provides additional information about brain function and potential injury.
D. The gag reflex is a protective mechanism to prevent choking and is assessed by stimulating the back of the throat. It is not included in the Glasgow Coma Scale. The GCS focuses on eye opening, verbal response, and motor response rather than reflexes.
E. Eye opening is the third component of the Glasgow Coma Scale. It assesses the patient’s ability to open their eyes spontaneously or in response to stimuli. This component helps determine the level of consciousness and alertness.

A. Lock the fingers together and pull against each other. B. Squeeze a thigh with the opposite hand. C. Stretch the arms over the head. D. Clench the jaw tightly

Correct Answer is A

Explanation

A. This maneuver is intended to engage other muscle groups and increase overall muscle tone. It can help facilitate the patellar reflex by increasing muscle tension and sensitivity. This technique can enhance the reflex response by engaging the client in a physical action that might make the reflex more pronounced.
B. Squeezing the thigh might create discomfort or involuntary muscle contraction, which could interfere with the reflex response. It is not a recommended technique for eliciting the patellar reflex and may not have a significant effect on reflex assessment.
C. Stretching the arms over the head does not directly influence the patellar reflex. Reflexes are typically assessed in a relaxed state, and this action might not be relevant for improving the patellar reflex response.
D. Clenching the jaw might increase overall muscle tone temporarily, but it does not directly impact the patellar reflex. This technique is less likely to influence the patellar reflex compared to techniques that engage lower body muscle groups.

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A patient is diagnosed with Meningitis. During the physical examination in the supine position, the nurse flexed the patient's neck and the patient flexed his knees and hip while complaining of neck pain. This is known as:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which are the 3 areas included in the Glasgow Coma Scale to assess levels of consciousness? Select all that Apply.

Correct Answer is ["A","B"]

Explanation

A nurse is having difficulty eliciting a patellar reflex. Which of the following would be most appropriate for the nurse to have the client do?

Correct Answer is A

Explanation

A patient is able to move both upper arms as follows: active movement against gravity, and some resistance. The nurse should document the muscle strength of the upper arms as:

When implementing nursing interventions for a client who has attempted suicide, which of the following is most important?

Taste in the 1/3 posterior of your tongue is given by:

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Stroke Warning signs includes? Select all that applied.

The nurse is admitting a client to the unit for surgery the next morning. The nurse notes that the client speaks at an accelerated pace and jumps from topic to topic no of which progresses to sensible conversation. What would the nurse document about this client?