The nurse is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity.

Which method should help the nurse assess for neck rigidity correctly?

Gently pressing the bones on the neck.

Moving the head toward both sides.

Lightly tapping the lower portion of the neck to detect sensation.

Moving the head and chin toward the chest.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Pressing the bones on the neck does not adequately assess for rigidity and may cause discomfort without providing useful information about the neurologic status.

Choice B rationale

Moving the head toward both sides is a method used to assess range of motion but does not specifically assess for neck rigidity, which requires specific positioning and movement.

Choice C rationale

Lightly tapping the lower portion of the neck to detect sensation does not assess for rigidity; it may be used to test sensory function rather than muscular stiffness or tension.

Choice D rationale

Moving the head and chin toward the chest is the standard method to assess for neck rigidity, especially in cases of suspected meningitis. This movement can reveal stiffness or resistance, which are key indicators of neurologic involvement.

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Correct Answer is ["B","C","D"]

Explanation

Choice A rationale

Tachycardia is not a symptom of Cushing's triad; it is often associated with other conditions such as stress or heart problems.

Choice B rationale

Bradypnea is a hallmark of Cushing's triad, indicating decreased respiratory rate due to increased intracranial pressure.

Choice C rationale

Hypertension is a key component of Cushing's triad, caused by increased intracranial pressure leading to elevated blood pressure.

Choice D rationale

Bradycardia, or a slower than normal heart rate, is a symptom of Cushing's triad, resulting from increased pressure in the brain affecting the heart rate.

Choice E rationale

Pupillary constriction is not typically associated with Cushing's triad; it is usually related to other neurological conditions.

A. Intravenous phenobarbital. B. Oral phenytoin. C. Intravenous diazepam. D. Oral lorazepam.

Correct Answer is C

Explanation

Choice A rationale

Intravenous phenobarbital can be used to treat status epilepticus, but it is not the first-line drug due to its slower onset of action compared to benzodiazepines. Rapid intervention is critical in status epilepticus, and phenobarbital is generally reserved for refractory cases.

Choice B rationale

Oral phenytoin is used for long-term control of seizures but is not effective for immediate cessation of status epilepticus. It takes longer to reach therapeutic levels and is not suitable for acute management.

Choice C rationale

Intravenous diazepam is a benzodiazepine with a rapid onset of action, making it effective in stopping seizures immediately. It enhances GABA activity, which has an inhibitory effect on neuronal firing, providing quick control of status epilepticus. This rapid effect is crucial for minimizing neuronal damage and other complications.

Choice D rationale

Oral lorazepam is effective for long-term management of seizures but is not appropriate for immediate treatment of status epilepticus. The oral route delays absorption and onset of action, making it unsuitable for acute seizure control. .

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The nurse is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly?

Nursing Test Bank

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Correct Answer is ["B","C","D"]

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Correct Answer is C

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The nurse is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity.

Which method should help the nurse assess for neck rigidity correctly?