Nokea
When assessing a child which finding would indicate the presence of Kernig's sign?
- A. Calf pain when the foot is dorsiflexed
- B. Pain when the chin is pulled down to the chest
- C. The inability of the child to extend the legs fully when lying supine
- D. The flexion of the hips when the neck is flexed from a lying position
Correct Answer: C
Rationale: Kernig's sign is the inability of the child to extend the legs fully when lying supine. Brudzinski's sign is flexion of the hips when the neck is flexed from a supine position. Both of these signs are frequently present in clients with bacterial meningitis. Nuchal rigidity is also present with bacterial meningitis, and it occurs when pain prevents the child from touching the chin to the chest. Homans' sign is elicited when pain occurs in the calf region when the foot is dorsiflexed.
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A client diagnosed with cirrhosis of the liver is receiving oral triamterene daily. Which sign/symptom would indicate to the nurse that the client is experiencing an adverse effect of the medication?
- A. Dry skin
- B. Excitability
- C. Constipation
- D. Hyperkalemia
Correct Answer: D
Rationale: Triamterene is a potassium-retaining diuretic. Adverse effects include hyperkalemia, dehydration, hyponatremia, and lethargy. Although the concern with most diuretics is hypokalemia, this is a potassium-retaining medication, which means that the concern with the administration of this medication is hyperkalemia. Other effects include nausea, vomiting, cramping, diarrhea, headache, ataxia, drowsiness, confusion, and fever.
The nurse is caring for a client diagnosed with acquired immunodeficiency syndrome (AIDS). Which sign/symptom indicates the presence of an opportunistic respiratory infection?
- A. Nausea and vomiting
- B. Fever and exertional dyspnea
- C. An arterial blood gas pH of 7.40
- D. A respiratory rate of 20 breaths per minute
Correct Answer: B
Rationale: Fever and exertional dyspnea are signs of Pneumocystis jiroveci pneumonia, which is a common, life-threatening opportunistic infection that afflicts those with AIDS. Option 1 is not associated with respiratory infection. Options 3 and 4 are normal findings.
The nurse prepares to administer a continuous intravenous (IV) infusion through a peripheral IV to a dehydrated client. Which priority assessment should the nurse obtain before initiating the IV infusion?
- A. Daily body weight
- B. Serum electrolytes
- C. Intake and output records
- D. Identifying the client's dominant side
Correct Answer: A
Rationale: The nurse obtains the client's baseline body weight as a priority before beginning the IV infusion because body weight is a sensitive and specific indicator of fluid volume status when body weights are compared on a daily basis. This means that as a client receives or accumulates fluid, body weight quickly and proportionately increases and vice versa. The remaining options may also be reasonable assessments to complete before initiating an IV infusion. However, intake, output, and serum electrolytes are potentially affected by more confounding factors; thus, they are less specific and sensitive to fluctuations in body fluid. Determining the client's dominant side assists in deciding a site for inserting the initial IV catheter, but it provides no information about fluid volume status.
The nurse is performing an assessment on a pregnant client with a history of cardiac disease. Which body area will venous congestion most commonly be noted in?
- A. Vulva
- B. Around the eyes
- C. Fingers of the hands
- D. Around the abdomen
Correct Answer: A
Rationale: Assessment of the cardiovascular system includes observation for venous congestion that can develop into varicosities. Venous congestion is most commonly noted in the legs, the vulva, or the rectum. Although edema may be noted in the fingers and around the eyes, edema in these areas would not be directly associated with venous congestion. It would be difficult to assess for edema in the abdominal area of a client who is pregnant.
A child experienced a basilar skull fracture that resulted in the presence of Battle's sign. Which should the nurse expect to observe in the child?
- A. Bruising behind the ear
- B. The presence of epistaxis
- C. A bruised periorbital area
- D. An edematous periorbital area
Correct Answer: A
Rationale: The most serious type of skull fracture is a basilar skull fracture. Two classic findings associated with this type of skull fracture are Battle's sign and raccoon eyes. Battle's sign is the presence of bruising or ecchymosis behind the ear caused by a leaking of blood into the mastoid sinuses. Raccoon eyes occur as a result of blood leaking into the frontal sinus and causing an edematous and bruised periorbital area.