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 B
Explanation
A. Keep the patient NPO (nothing by mouth) until the T-tube is removed. Patients are generally kept NPO initially but may resume clear liquids and progress to a regular diet based on tolerance; NPO status is not required until the T-tube is removed.
B. Monitor the tube drainage and document the amount and color. Monitoring and documenting drainage from the T-tube is crucial to assess biliary function and ensure that the bile is draining properly, indicating no obstruction.
C. Ensure the tube is clamped for 8 hours each day. Clamping may be done before tube removal to test the body’s tolerance to bile drainage, but it should be done only as per physician orders, not routinely for 8 hours each day.
D. Flush the T-tube with normal saline every 4 hours. Flushing a T-tube is generally not done routinely as it could disrupt the flow of bile and cause complications.
Correct Answer is C
Explanation
A. Initiate intravenous fluid therapy. While fluid therapy is essential to support circulation and reduce the risk of shock, oxygenation takes priority in fat embolism management.
B. Prepare the client for emergency surgery. Surgery is not typically the first-line intervention for fat embolism; management focuses on supportive care, particularly respiratory support.
C. Administer high-flow oxygen via a non-rebreather mask. High-flow oxygen is the first priority to address hypoxia caused by fat embolism and should be administered immediately to maintain adequate oxygenation.
D. Apply sequential compression devices (SCDs). SCDs are used to prevent venous thromboembolism, but they do not help with the treatment of fat embolism.