The nurse has placed her hands behind the client's head and flexed his neck forward as far as he can tolerate. During the test the client experiences leg pain and bends his knees. In addition, he complains of neck pain. This assessment finding is suggestive of what health problem?

Ischemic stroke

Trigeminal neuralgia

Meningitis

Bell's palsy

Answer and Explanation

The Correct Answer is C

Choice A reason: Ischemic stroke causes focal deficits like weakness, not neck flexion-induced leg pain. This vascular event lacks meningeal irritation signs, misaligning with the positive Brudzinski’s sign of knee bending and neck pain in this assessment fully here.
Choice B reason: Trigeminal neuralgia triggers facial pain, not leg or neck pain with flexion. This cranial nerve V issue doesn’t involve meningeal inflammation, excluding it from the systemic response seen in this neck maneuver entirely and accurately here.
Choice C reason: Meningitis causes meningeal irritation; neck flexion (Brudzinski’s sign) elicits leg pain and knee bending. Neck pain aligns with inflammation, making this the likely diagnosis for the client’s response to this specific neurological test comprehensively here.
Choice D reason: Bell’s palsy affects cranial nerve VII, causing facial paralysis, not leg or neck pain. This peripheral nerve issue lacks the meningeal signs triggered by neck flexion, ruling it out as the cause in this scenario fully here.

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Correct Answer is A

Explanation

Choice A reason: Tonsils touching the uvula indicate 4+ grading, where they obstruct over 75% of the oropharynx. This severe enlargement, with sore throat, fits the highest scale, reflecting significant inflammation or infection impacting airway and swallowing, accurately documented here.

Choice B reason: 1+ tonsils are slightly enlarged, less than 25% of the oropharynx, visible but not near the uvula. This underestimates the finding of tonsils contacting the uvula, misrepresenting the degree of obstruction and inflammation present in this case entirely.

Choice C reason: 2+ tonsils occupy 25-50% of the oropharynx, not touching the uvula. This moderate grade doesn’t match the observed contact, understating the severity of enlargement and potential airway compromise noted during the inspection clearly and significantly.

Choice D reason: 3+ tonsils cover 50-75% of the oropharynx, nearing but not contacting the uvula. This is close but inaccurate, as the finding shows full contact, warranting the higher 4+ grade for precise documentation of this advanced tonsillar size fully.

A. Blood is returning from the client's toe more slowly than normal. B. There is a disruption in osmotic pressure in the client's extremities. C. There is a blockage or infection in the client's lymphatic system. D. The client's toe is receiving an inadequate supply of blood.

Correct Answer is D

Explanation

Choice A reason: Slow venous return causes edema, not deep, painful wounds. This venous issue lacks the arterial insufficiency link to tissue necrosis, misaligning with the circular ulcer’s ischemic profile, which requires oxygen delivery, not just drainage, here fully.

Choice B reason: Osmotic pressure disruption affects fluid balance, not localized wounds. This systemic issue doesn’t explain a toe ulcer’s depth and pain, missing the vascular supply deficit driving tissue breakdown in this specific extremity finding entirely and clearly.

Choice C reason: Lymphatic blockage or infection causes swelling or lymphangitis, not deep, circular wounds. This lacks the ischemic etiology of toe ulcers, which stem from arterial insufficiency, not lymphatic dysfunction, distinguishing it from the observed pathology here fully.

Choice D reason: Inadequate arterial blood supply, as in peripheral artery disease, causes deep, painful toe ulcers due to tissue ischemia. Poor oxygen delivery leads to necrosis, matching the wound’s characteristics, making this the most likely etiology accurately and precisely.

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The nurse has placed her hands behind the client's head and flexed his neck forward as far as he can tolerate. During the test the client experiences leg pain and bends his knees. In addition, he complains of neck pain. This assessment finding is suggestive of what health problem?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse's inspection of a client's extremities reveals a deep, circular, painful wound on the client's great toe. What should the nurse suspect as the etiology of the client's wound?

Correct Answer is D

Explanation

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