The nurse in the clinic is assessing a young child brought in by the parents with symptoms of meningitis. The nurse will assess for
The Correct Answer is {"dropdown-group-1":"E"}
Brudzinski sign is a clinical sign of meningitis, an inflammation of the membranes that cover the brain and spinal cord. It is characterized by reflexive flexion of the knees and hips following passive neck flexion13. To test for this sign, the examiner places one hand on the chest and the other behind the neck of the patient lying flat on the back, and then lifts the head forward. Brudzinski sign was first described by Polish pediatrician Józef Brudziński over 100 years ago. It may be absent, especially in young children.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Measure abdominal girth according to a set routine. Abdominal enlargement is a common finding in clients with cirrhosis, which is a condition characterized by liver scarring and impaired liver function. Measuring abdominal girth regularly is an important nursing intervention to monitor the progression of abdominal distention and to identify potential complications such as ascites, which is an accumulation of fluid in the abdomen.
Choice A, reporting the condition to the physician immediately, may be necessary if the abdominal enlargement is sudden or accompanied by other symptoms such as severe pain or shortness of breath.
Choice B, providing the client with nonprescription laxatives, is not indicated for abdominal enlargement in clients with cirrhosis.
Choice D, asking the client about food intake, is not relevant to the assessment of abdominal enlargement in clients with cirrhosis.
Correct Answer is A
Explanation
Monitoring the rate of IV infusions. In clients with diabetes insipidus, fluid therapy is essential to restore hydration levels. It is important to monitor the rate of IV infusion to avoid rapid administration of fluids, which can lead to fluid overload and pulmonary edema. Therefore, monitoring the rate of IV infusions is the most important intervention for this client.
Choice B, weighing the client daily, is incorrect because it is not the most important intervention for this client. While daily weighing is important for monitoring fluid balance, monitoring the rate of IV infusion is more critical.
Choice C, measuring the urine output every 30 minutes, is incorrect because although it is important to monitor urine output in clients with diabetes insipidus, it is not the most important intervention. Monitoring the rate of IV infusion is more critical to prevent fluid overload.
Choice D, measuring the fluid intake, is incorrect because although it is important to monitor fluid intake in clients with diabetes insipidus, it is not the most important intervention. Monitoring the rate of IV infusion is more critical to prevent fluid overload.
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