The nurse notes documentation that a child with meningitis is exhibiting a positive Kernig's sign. Which observation is a characteristic of this sign?
Petechial and purpuric rashes are noted on the child's trunk
Neck flexion causes adduction and flexion movements of the lower extremities
The child is not able to extend the leg when the thigh is flexed anteriorly at the hip
The child complains of muscle and joint pain
The Correct Answer is C
C. This is characteristic of Kernig's sign. Kernig's sign is elicited when the thigh is flexed at the hip and then attempts to extend the leg at the knee are met with resistance or pain due to inflammation of the meninges.
A. Petechial and purpuric rashes are associated with meningococcal meningitis, not specifically with Kernig's sign. These rashes result from bleeding into the skin and are a characteristic feature of meningococcal sepsis. However, they are not directly related to Kernig's sign.
B. This observation describes Brudzinski's sign, not Kernig's sign. Brudzinski's sign occurs when passive flexion of the neck causes involuntary flexion of the hips and knees due to meningeal irritation.
D. Muscle and joint pain can be symptoms of meningitis, but they are not specific to Kernig's sign. Kernig's sign specifically refers to resistance or pain experienced when attempting to extend the leg at the knee.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Tugging or pulling on the affected ear lobe is a classic sign of otitis media in infants. The discomfort or pain caused by inflammation and pressure in the middle ear may lead the infant to tug or rub the affected ear in an attempt to alleviate discomfort.
A. Bluish-green discharge from the ear canal is not a typical finding in otitis media. Otitis media is characterized by inflammation and fluid accumulation in the middle ear, which may not result in discharge unless there is a secondary bacterial infection or perforation of the eardrum.
B. An increase in appetite is not a typical finding in otitis media. In fact, many children with otitis media may experience a decrease in appetite due to discomfort, pain, and difficulty swallowing or chewing.
C. Erythema (redness) and edema (swelling) of the affected auricle (outer ear) are not typically associated with otitis media. Otitis media primarily affects the middle ear, where inflammation and fluid accumulation occur behind the eardrum.
Correct Answer is B
Explanation
The nurse should ensure that the rope knots are positioned away from the pulleys to prevent interference with the traction mechanism. Proper alignment of the rope and pulleys ensures smooth traction application and prevents accidental slippage or dislodgment of the traction weights.
A. Buck's traction typically does not involve pin sites. It involves the application of traction to the affected limb using a boot or traction tape. Antibiotic ointment is not typically applied to the skin under Buck's traction unless there are specific wounds or abrasions that require treatment.
C. Ensuring the child's feet are against the footboard is not applicable to Buck's traction, which does not require the feet to be against a footboard.
D. There is typically no need to reduce a child's fluid intake solely because they are in Buck's traction for Legg-Calve-Perthes disease. Adequate hydration is essential for overall health and healing, and fluid restriction is not indicated unless there are specific medical reasons for doing so.
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