The nurse is assessing the client and anticipates which of the following as early signs of meningitis? (Select all that apply.)
1. Chills
2. Seizures and paralysis
3. Nuchal rigidity
4. Positive Kernig's sign
5. Negative Brudzinski sign
3. Nuchal rigidity
4. Positive Kernig's sign
Rationale:
Nuchal rigidity, or pain when flexing the neck, is a classic symptom of meningitis resulting from inflammation of the meninges. Positive Kernig's sign is found when the client cannot extend the leg when the hip is flexed at a 90° angle. Brudzinski sign, or neck flexion causing the knees and hips to flex, would also be positive. Seizures, paralysis, fever, and chills would all be late signs of meningitis.
You might also like to view...
A nurse is teaching a client with psoriatic arthritis about the medication golimumab (Simponi). What information is most important to include?
a. "Avoid large crowds or people who are ill." b. "Stay upright for 1 hour after taking this drug." c. "This drug may cause your hair to fall out." d. "You may double the dose if pain is severe."
When counseling parents of an adolescent boy who are concerned about mood disturbances, the nurse suggests the probability of depression since what percentage of adolescents experience it?
a. 3 b. 5 c. 8 d. 12
There is no difference is lifetime prevalence rates of major mental illness between developed and developing countries. Despite the prevalence and disability associated with major mental illness,
these disorders are much more likely to be untreated than physical illness at every income level. Using your knowledge about the scope of mental illness, what mental health illness has the highest percentage of individuals who go untreated? A) Anxiety B) Bipolar disorders C) Depression D) Alcoholism and addictive disorders
A nursing student is in her senior year of nursing school. She is caring for three patients for a busy surgical unit. One of the patients is confused and has been restrained to prevent him from injuring himself
Which of the following is a priority as she plans her care for the shift? A. Calling the physician for an order for a chemical restraint B. Requesting restraint alternatives from the physician for her patient who is restrained C. Removing the restraints on the patient at least every 2 hours D. Checking on the restrained patient last because he cannot get out of bed