The nurse is admitting a client with suspected meningitis. During the assessment, the nurse asks the client to flex the chin down toward the chest. The client verbalizes pain and stiffness during this action

Question

How will the nurse document this finding in the medical record?
1. Muscle spasms.
2. Neck strain.
3. Nuchal rigidity.
4. Brudzinski's sign.

Answer 1

Correct Answer: 3
Nuchal rigidity occurs with meningeal irritation, which will cause pain and neck stiffness. The presence of muscle spasms are not associated with meningitis and are not elicited in this manner. Neck strain is not associated with meningitis. The assessment of neck strain would not involve having the client flex the chin toward the chest. Brudzinski's sign is assessed in clients suspected of having meningitis. The sign is present when neck flexion causes flexion of the legs and thighs.