Ms. N has an elevated temperature and complains of a severe headache, nausea, and vomiting. Suspecting meningitis, you decide to assess for other signs of meningeal irritation, which include
a. Lasègue's and Hoffman's signs.
b. Chaddock's reflex and Tromner's sign.
c. Kernig's and Brudzinski's signs.
d. Oppenheim's sign and Gordon's reflex.
C
To assess the patient for signs of meningeal irritation, look for nuchal rigidity, Kernig's sign, and Brudzinski's sign, all abnormal findings. Other signs and symptoms include violent headache, photophobia, fever, nausea and vomiting, decreasing level of consciousness, and seizures. A definitive diagnosis is obtained through cultures of cerebrospinal fluid.
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A client tells the nurse that she wants to be checked for a bowel infection because she has been constipated. The nurse should instruct this client that constipation is NOT caused by:
a. low-fiber diet. c. diverticular disease. b. dehydration. d. infectious agents.
The nurse is aware of the typical occurrence of comorbidities in the older adult. Motivated by this knowledge, the nurse assesses a patient with diagnosed respiratory dysfunction for possible
a. poor wound healing of the legs and feet. b. ineffective absorption of vitamins and minerals. c. abnormal urine protein levels. d. visual problems including retinal detach-ment.
A client with hypoparathyroidism has a low serum calcium level. In order to test for the clinical manifestation consistent with this laboratory result, the nurse would: Select all that apply
1. Tap over the facial nerve of the client. 2. Place a tourniquet on the client's arm. 3. Have the client open and close both hands. 4. Ask the client to count backwards. 5. Press lightly on the client's shoulders.
A patient is thought to have a balance problem. What would be an advanced method of assessing balance in this patient? (Mark all that apply.)
A) Walking heel to toe B) Standing on one foot C) Romberg's test D) Standing E) Hopping on one foot