The patient is supine and the head is flexed to the chest without pain, resistance, or flexion of the hips or knees. The nurse is observing for which finding?
1. Doll's eyes reflex
2. Brudzinski sign
3. Babinski reflex
4. Kernig's sign
2
Rationale 1: In the doll's eyes reflex, the eyes move in the opposite direction in which the head is turned.
Rationale 2: The Brudzinski sign is elicited by placing the patient in a supine position and flexing the neck toward the chest. A positive result would be noted if the patient has pain or flexes the hip or knees in response to the neck flexion. A positive response indicates meningeal irritation.
Rationale 3: The Babinski reflex is the extensor plantar response. An abnormal response is dorsiflexion of the big toe and often a fanning of the other toes.
Rationale 4: To assess for Kernig's sign, the patient, in the supine position, flexes the hip and extends the leg. Bilateral pain in the hamstring area that prevents straightening of the leg is a positive sign of meningitis.
You might also like to view...
A nurse is caring for a client who is prescribed thyroid hormone replacement. From which of the following signs during ongoing assessment should the nurse conclude that the client is responding to the therapy?
A) Increased appetite B) Swollen neck C) Excessive sweating D) Flushing
The public health nurse is teaching a group of parents about immunizations
The nurse tells that parents that after receiving the varicella virus vaccine, children should temporarily avoid close contact with which of the following? (Select all that apply.) a. Neonates b. Siblings c. Relatives over age 65 d. Pregnant women e. Individuals infected with HIV
Which response by the nurse is most appropriate to this statement: "This test isn't my idea, but my husband insists"?
a. "Don't worry. Everything will be fine." b. "Why don't you want to have this test?" c. "You're concerned about having this test?" d. "It's your decision."
The nurse teaching a young women's community service group about breast self-examination (BSE) will include that
a. BSE will reduce the risk of dying from breast cancer. b. BSE should be done daily while taking a bath or shower. c. annual mammograms should be scheduled in addition to BSE. d. performing BSE after the menstrual period is more comfortable.