The nurse assesses a patient who potentially may have meningitis. The patient demonstrates a positive Brudzinski's sign with which changes in position.
Flexion of the hip causes resistance to extension of the leg.
Flexion of the neck causes flexion of the hips and knees.
Flexion of the ankle causes upward fanning of the toes.
Flexion of the neck causes pain and spasm in the leg muscles.
The Correct Answer is B
Choice A reason: Flexion of the hip causing resistance to extension of the leg is not a sign of meningitis. It is a sign of hip joint inflammation or injury.
Choice B reason: Flexion of the neck causing flexion of the hips and knees is a positive Brudzinski's sign. It indicates irritation of the meninges, the membranes that cover the brain and spinal cord.
Choice C reason: Flexion of the ankle causing upward fanning of the toes is not a sign of meningitis. It is a sign of an upper motor neuron lesion, such as a stroke or spinal cord injury.
Choice D reason: Flexion of the neck causing pain and spasm in the leg muscles is not a sign of meningitis. It is a sign of muscle strain or nerve compression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Risk for Falls is the priority nursing diagnosis for a patient with Parkinson disease, as the disease affects the patient's balance, coordination, and posture. The patient may have difficulty walking, turning, and standing, which increases the risk of falling and injuring themselves. The nurse should implement interventions to prevent falls, such as providing assistive devices, removing environmental hazards, and educating the patient and family about fall prevention.
Choice B reason: Ineffective Self-Care Ability related to cognitive deficit is a possible nursing diagnosis for a patient with Parkinson disease, as the disease may impair the patient's memory, judgment, and problem-solving skills. The patient may have difficulty performing activities of daily living, such as bathing, dressing, and grooming. The nurse should assess the patient's self-care abilities, provide assistance as needed, and encourage the patient to maintain their independence and dignity.
Choice C reason: Risk for Impaired Skin Integrity related to uncontrolled hand tremors is another possible nursing diagnosis for a patient with Parkinson disease, as the disease causes involuntary movements of the hands, arms, and legs. The patient may scratch, rub, or injure their skin due to the tremors. The nurse should monitor the patient's skin condition, provide skin care, and protect the patient from skin breakdown.
Choice D reason: Nutrition: Less Than Body Requirements related to frequent nausea during meals is a potential nursing diagnosis for a patient with Parkinson disease, as the disease may affect the patient's appetite, digestion, and swallowing. The patient may experience nausea, vomiting, constipation, or dysphagia, which can lead to malnutrition and dehydration. The nurse should assess the patient's nutritional status, provide dietary modifications, and ensure adequate fluid intake.
Correct Answer is B
Explanation
Choice A (Apples and grapes): While fruits like apples and grapes are generally healthy options, they may not be the best choice for a client in sickle cell crisis. These fruits are high in fiber and may require a significant amount of chewing, which can be challenging for someone experiencing a sickle cell crisis.
Choice B (Popsicles, gelatin, or juice): This choice is the most suitable for a client in sickle cell crisis. During a crisis, it's important to stay hydrated, and these options provide hydration along with easily digestible carbohydrates, which can be beneficial for maintaining energy levels.
Choice C (Beans): While beans are a good source of protein and fiber, they may not be well tolerated during a sickle cell crisis due to their high fiber content.
Choice D (Cheese): Although cheese is a source of protein and calcium, it may not be the best option during a sickle cell crisis, as dairy products can be harder to digest and may not contribute to hydration.
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