Which neurologic assessment is being performed in the exhibit?
1. Kernig's sign
2. Babinski reflex
3. Brudzinski sign
4. Decorticate posturing
3
Rationale 1: To assess for Kernig's sign, the patient, in the supine position, flexes the hip and extends the leg.
Rationale 2: The Babinski reflex occurs when the big toe moves toward the top of the foot and the other toes fan out after the sole of the foot has been firmly stroked. This reflex is normal in younger children, but abnormal after the age of 2.
Rationale 3: To test for Brudzinski sign, the nurse flexes the patient's head to the chest with the patient supine. If pain, resistance, or flexion of the hips or knees occurs, this indicates meningeal irritation.
Rationale 4: Patients with decorticate posturing present with the arms flexed or bent inward on the chest, the hands clenched into fists, the legs extended, and the feet turned inward.
You might also like to view...
You are caring for a patient on mechanical ventilation with 10 cm H2O of PEEP. The patient becomes suddenly dyspneic. The trachea is deviated toward the left and breath sounds are absent on the right. You suspect
A) atelectasis. B) tension pneumothorax. C) pulmonary edema. D) intubation of right mainstem bronchus.
A patient comes into the community clinic speaking a language in which there are no interpreters available. Which action should the population health nurse take to demonstrate cultural competence within the healthcare system?
1. Ask the patient to seek medical care in the community hospital. 2. Ask a staff member if they could attempt to communicate with the patient. 3. Communicate to the patient that an interpreter is not available and ask them to return tomorrow. 4. Contact a neighboring community health center to find out if their interpreter for this patient's language can be borrowed for a short time.
In response to an HIV-infected patient asking about tuberculosis (TB), the nurse should explain that:
A) TB is often transmitted at the time of HIV transmission. B) HIV infection increases the risk of acquiring TB. C) HIV suppresses the activation of latent TB. D) TB is the leading cause of death in HIV-infected people.
The supplemental protein in the above example is a(an):
A. dependent variable. B. independent variable. C. extraneous variable. D. intervening variable.