The nurse is assessing a patient with suspected bacterial meningitis and notes a positive Kernig sign. How should the nurse interpret this finding?
Pain in the neck when the patient flexes their head towards the chest
Involuntary flexion of the hips and knees when the neck is flexed
Photophobia and headache triggered by bright light
Pain and resistance when attempting to extend the patient's leg from a flexed position
The Correct Answer is D
A. Pain in the neck when the patient flexes their head towards the chest. This describes nuchal rigidity, not Kernig sign.
B. Involuntary flexion of the hips and knees when the neck is flexed. This describes Brudzinski sign, not Kernig sign.
C. Photophobia and headache triggered by bright light. These are symptoms of meningitis, but they are not specific to Kernig sign.
D. Pain and resistance when attempting to extend the patient's leg from a flexed position. A positive Kernig sign is when there is pain and resistance to leg extension from a flexed hip and knee position, indicating meningeal irritation.
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Correct Answer is D
Explanation
A. I need to monitor the puncture site for signs of infection such as redness or swelling. Monitoring the puncture site is crucial for detecting any signs of infection or complications, which the patient should be aware of.
B. I should follow a heart-healthy diet to support my recovery. A heart-healthy diet is recommended to manage cholesterol levels and prevent further coronary artery disease progression.
C. I will take my prescribed medications as directed by my doctor. Following the medication regimen is important for preventing complications and supporting recovery, especially for blood thinners or other cardiac medications.
D. I can resume my regular physical activities immediately after I get home. This statement indicates a need for further teaching, as patients should gradually resume physical activities and avoid strenuous activities immediately after PTCA to prevent complications, such as bleeding at the catheter insertion site.
Correct Answer is ["A","C","E"]
Explanation
A. A clean catch urinalysis and urine culture: A urinalysis and culture are essential to identify the presence of infection, type of bacteria, and appropriate antibiotic sensitivity.
B. Foley catheter placement: Foley catheters are not routinely indicated for suspected urinary tract infections (UTIs) unless there is an issue with urinary retention or other specific medical indication.
C. Broad-spectrum antibiotic: Initiating a broad-spectrum antibiotic may be appropriate while waiting for culture results to address infection.
D. 0.9% sodium chloride infusion at 100 ml/hr: IV fluids are not typically necessary for a UTI unless the patient is dehydrated or unable to take oral fluids.
E. WBC count: A WBC count can help assess the systemic inflammatory response and gauge the severity of the infection.
F. Blood cultures × 2: Blood cultures are generally reserved for cases where a systemic infection or sepsis is suspected, which is not indicated by this patient's symptoms alone.