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. Initiation of a high-sodium diet. A high-sodium diet is not indicated in pulmonary embolism management; it could worsen fluid retention and cardiovascular strain.
B. Application of a cast to the affected limb. Casting is not appropriate for pulmonary embolism, as it is not an orthopedic injury. Immobilization could increase the risk of further clot formation.
C. Administration of anticoagulant therapy. Anticoagulant therapy, such as heparin or warfarin, is the primary treatment for pulmonary embolism to prevent further clot formation and allow the body to dissolve the clot.
D. Administration of bronchodilators. Bronchodilators may alleviate respiratory symptoms but do not treat the underlying clot in pulmonary embolism. Anticoagulation remains the primary treatment.
Correct Answer is D
Explanation
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.