A nurse is ordered to observe a female client suspected to have meningitis for positive Brudzinski's sign. Which of the following would the nurse document as a positive Brudzinski's sign?
A) Evidence of pain when the client lies on the back and brings one leg up so that the hip and knee are flexed at 90 degrees.
B) Evidence of pain when the client lies on the side and brings one leg up so that the hip and knee are flexed at 90 degrees
C) Evidence of pain or resistance when the client lies on the back and brings her head forward toward the chest
D) Evidence of pain or resistance when the client lies on the side and brings her head forward toward the chest
C
Feedback:
The nurse should document evidence of pain when the client lies on her back and brings her head forward toward the chest as a positive Brudzinski's sign. Evidence of pain when the client lies on her back and brings one leg up so that the hip and knee are flexed at 90 degrees is seen in a positive Kernig's sign. Kernig's sign also is considered a positive indicator of meningitis. Evidence of pain when the client lies on her side and brings one leg up so that the hip and knee are flexed at 90 degrees, or when the client lies on the side and brings her head forward toward the chest, does not indicate a positive Brudzinski's sign.
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