Stroke Warning signs includes? Select all that applied.

Kernig sign

Arm Weakness

Sudden confusion or trouble understanding

Face Drooping

negative Babinski reflex

Speech Difficulty

Answer and Explanation

Correct Answer : B,C,D

A.   The Kernig sign is a clinical test used to diagnose meningitis, not stroke. It involves flexing the patient’s hip and knee and then attempting to extend the knee while the hip is flexed. Pain or resistance during this maneuver can suggest meningeal irritation.
B.   Arm weakness refers to the loss of strength or control in one or both arms, which can be a sign of a stroke. It may be noticeable when a person is unable to lift their arm or keep it raised.
C.   Sudden confusion, trouble understanding, or difficulty speaking can be signs of a stroke. This may involve problems with language or comprehension, which are related to the areas of the brain responsible for these functions.
D.   Face drooping, especially on one side of the face, is a classic sign of stroke. It occurs when the muscles on one side of the face weaken or become paralyzed.
E.   The Babinski reflex is a test where the sole of the foot is stroked, and the normal response in adults is the downward flexion of the toes. An abnormal Babinski reflex (upward extension of the big toe) can indicate neurological problems but is not a specific warning sign of stroke.
F.   Speech difficulty, such as slurred speech or trouble finding words, is a common sign of a stroke. It can involve problems with articulation, coherence, or understanding language.

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Correct Answer is B

Explanation

A. A reflex grade of 2+ is considered normal. It indicates that the reflex is present and of normal intensity, with a typical response.
B. A reflex grade of 3+ is considered brisk. It indicates that the reflex is more pronounced than normal
but not necessarily pathological. It’s often described as "brisk" or "exaggerated."
C. A reflex grade of 1+ is considered diminished or hypoactive. It indicates that the reflex is present but less intense than normal.
D. A reflex grade of 4+ is considered very brisk or hyperactive. It indicates a reflex response that is exaggerated and may suggest an upper motor neuron lesion or other neurological abnormalities.

A. Check for a Babinski reflex B. Position the client prone C. Ensure no injury to the cervical spine D. Check for evidence of fever and chills

Correct Answer is C

Explanation

A. The Babinski reflex is a test used to assess the integrity of the corticospinal tract and is particularly useful in evaluating neurological function in infants and adults with neurological conditions. However, it is not specifically related to testing for meningeal irritation.
B. Positioning the client prone (lying on their stomach) is not typically used when testing for meningeal irritation. The tests for meningeal irritation, such as the Brudzinski sign and Kernig sign, are performed with the client in a supine (lying on their back) position to accurately assess reactions to neck flexion and leg movements.
C. Before performing tests for meningeal irritation, such as neck flexion, it is important to ensure that the client does not have an injury to the cervical spine. If there is a possibility of cervical spine injury, performing neck flexion could exacerbate the injury. Ensuring that there is no cervical spine injury helps to avoid causing harm and ensures a safe examination.
D. While fever and chills can be associated with infections that may cause meningeal irritation (such as meningitis), checking for these symptoms is not the first step in assessing meningeal irritation itself.

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Stroke Warning signs includes? Select all that applied.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses brisk reflexes in a client. The nurse would document this finding as which of the following?

Correct Answer is B

Explanation

When preparing to test a client for meningeal irritation, what would the nurse do first?

Correct Answer is C

Explanation

Which of the following tests would be most appropriate for the nurse to use when assessing motor function of the trigeminal nerve?

Loss of bone density that occurs with greatest frequency in postmenopausal women is called?

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After a physical assessment, the nurse determines that a client has full range of motion of the temporomandibular joint. Which of the following assessments did the nurse complete with the client? Select all that apply.

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