Nokea
The nurse is assessing the client diagnosed with bacterial meningitis. Which clinical manifestations would support the diagnosis of bacterial meningitis?
- A. Positive Babinski’s sign and peripheral paresthesia.
- B. Negative Chvostek’s sign and facial tingling.
- C. Positive Kernig’s sign and nuchal rigidity.
- D. Negative Trousseau’s sign and nystagmus.
Correct Answer: C
Rationale: Kernig’s sign (pain with leg extension) and nuchal rigidity (C) are hallmark signs of bacterial meningitis due to meningeal irritation. Other options include unrelated or less specific findings.
You may also like to solve these questions
Which intervention is most effective for managing autonomic dysreflexia in a client with a spinal cord injury?
- A. Elevate the head of the bed.
- B. Administer a bronchodilator.
- C. Apply a warm compress to the abdomen.
- D. Insert a urinary catheter immediately.
Correct Answer: D
Rationale: Autonomic dysreflexia is often triggered by bladder distension; immediate catheterization relieves the stimulus.
The client, diagnosed with an ischemic stroke, is being evaluated for thrombolytic therapy. Which assessment finding should prompt the nurse to withhold thrombolytic therapy?
- A. Brain CT scan results show no bleeding.
- B. Had a serious head injury four weeks ago.
- C. Has a history of type 1 diabetes mellitus.
- D. Neurological deficits started 2 hours ago.
Correct Answer: B
Rationale: A negative CT scan is a criterion for administering the thrombolytic therapy. Contraindications to thrombolytic therapy for the client with an ischemic stroke include a serious head injury within the previous 3 months. This would put the client at risk of developing serious bleeding problems, specifically cerebral hemorrhage. History of type 1 DM is not a contraindication for thrombolytic therapy. The onset of neurological deficits within 3 hours is a criterion for administering thrombolytic therapy.
Which client statement indicates a need for further teaching about post-craniotomy care?
- A. I'll avoid coughing forcefully.'
- B. I'll sleep with my head elevated.'
- C. I can lift heavy objects after a week.'
- D. I'll report severe headaches immediately.'
Correct Answer: C
Rationale: Lifting heavy objects post-craniotomy can increase intracranial pressure; clients should avoid this for several weeks.
Which of the following indicates an autonomic nervous system manifestation of a seizure?
- A. Numbness and tingling of the hands
- B. Changes in taste and speech
- C. Flushing and increased sweating
- D. A subjective aura or sensation
Correct Answer: C
Rationale: Flushing and increased sweating are autonomic nervous system manifestations that can occur during a seizure, reflecting involuntary physiological changes.
The client is being evaluated to rule out ALS. Which signs/symptoms would the nurse note to confirm the diagnosis?
- A. Muscle atrophy and flaccidity.
- B. Fatigue and malnutrition.
- C. Slurred speech and dysphagia.
- D. Weakness and paralysis.
Correct Answer: C
Rationale: Slurred speech and dysphagia (C) are early ALS signs due to bulbar muscle involvement. Atrophy/flaccidity (A) and weakness/paralysis (D) occur later, and fatigue/malnutrition (B) are nonspecific.