When preparing to test a client for meningeal irritation, what would the nurse do first?

Check for a Babinski reflex

Position the client prone

Ensure no injury to the cervical spine

Check for evidence of fever and chills

Answer and Explanation

The Correct Answer is C

A.   The Babinski reflex is a test used to assess the integrity of the corticospinal tract and is particularly useful in evaluating neurological function in infants and adults with neurological conditions. However, it is not specifically related to testing for meningeal irritation.
B.   Positioning the client prone (lying on their stomach) is not typically used when testing for meningeal irritation. The tests for meningeal irritation, such as the Brudzinski sign and Kernig sign, are performed with the client in a supine (lying on their back) position to accurately assess reactions to neck flexion and leg movements.
C.   Before performing tests for meningeal irritation, such as neck flexion, it is important to ensure that the client does not have an injury to the cervical spine. If there is a possibility of cervical spine injury, performing neck flexion could exacerbate the injury. Ensuring that there is no cervical spine injury helps to avoid causing harm and ensures a safe examination.
D.   While fever and chills can be associated with infections that may cause meningeal irritation (such as meningitis), checking for these symptoms is not the first step in assessing meningeal irritation itself.

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Correct Answer is B

Explanation

A. Extinction refers to the phenomenon where a person fails to recognize a stimulus on one side of the body when another stimulus is presented simultaneously on the opposite side. This is often tested in cases of neurological impairment, particularly in the context of sensory neglect or loss
B. Stereognosis is the ability to identify an object by touch and proprioception without visual input. It involves recognizing the shape, size, and texture of an object solely through tactile information. Placing a coin in the patient’s hand and asking them to identify it with their eyes closed tests their ability to use tactile information to recognize objects, making stereognosis the correct term for this assessment.
C. Proprioception is the sense of the position and movement of the body and its parts. It involves awareness of body position in space, which is crucial for coordination and balance. While important, proprioception does not specifically involve identifying objects by touch alone; it is more about the awareness of body position.
D. Two-point discrimination is the ability to distinguish between two closely spaced points of contact on the skin. It tests the sensitivity of the skin to touch and is often used to assess sensory nerve function. It does not involve identifying objects by touch but rather measuring how well one can discern between two separate points of contact.

A. Glossopharyngeal B. Trigeminal C. Vagus D. Facial

Correct Answer is B

Explanation

A. The glossopharyngeal nerve is involved in several functions, including taste sensation on the posterior third of the tongue, salivation, and the sensation of the pharynx. It also plays a role in swallowing and gag reflex. However, it is not responsible for the movement of the jaw or clenching of the jaw.
B. The trigeminal nerve is responsible for sensation in the face and also controls the muscles of mastication (chewing). It has both sensory and motor functions. The motor branches of the trigeminal nerve, specifically the mandibular division, innervate the muscles that allow for jaw movement, including clenching.
C. The vagus nerve has a broad range of functions, including regulating heart rate, digestive tract motility, and some aspects of speech and swallowing. It does not control jaw movement or clenching, so it is not relevant to this observation.
D. The facial nerve controls the muscles of facial expression, including movements like smiling, frowning, and closing the eyes. It is not involved in the motor control of the jaw or clenching actions.

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When preparing to test a client for meningeal irritation, what would the nurse do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse places a coin in the patient's hand, the patient is with eyes closed. The ability to identify an object by feeling it is defined as:

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

The nurse assesses brisk reflexes in a client. The nurse would document this finding as which of the following?

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