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 C
Explanation
A. Encourage the client to walk on the injured ankle to promote circulation. Weight-bearing activities should be avoided initially after a Grade II sprain to prevent further injury.
B. Immerse the ankle in warm water immediately after the injury. Ice, rather than warmth, is recommended immediately following an injury to reduce swelling and inflammation.
C. Apply ice to the affected ankle for the first 24-72 hours. Applying ice for 24-72 hours helps reduce swelling and pain by causing vasoconstriction and controlling inflammation in the acute phase.
D. Perform deep tissue massage on the injured area to reduce pain. Massaging a newly sprained ankle can aggravate inflammation and cause additional tissue damage.
Correct Answer is C
Explanation
A. Loss of pain, temperature, and light touch sensation on the same side as the injury. In Brown-Sequard syndrome, pain, temperature, and light touch are typically lost on the opposite (contralateral) side of the injury.
B. Loss of motor function and deep pressure sensation on the opposite side of the injury. Motor function and deep pressure sensation loss occur on the same side (ipsilateral) as the injury.
C. Loss of motor function and position sense on the same side as the injury. Brown-Sequard syndrome is a spinal cord hemisection injury leading to loss of motor function and proprioception on the same side as the injury.
D. Loss of motor function with preserved pain and temperature sensation in the lower extremities. Pain and temperature sensations are lost on the opposite side of the injury in Brown-Sequard syndrome, not preserved.