After the examination of an infant, the nurse documents opisthotonos. The nurse recognizes that this finding often occurs with:

a. Cerebral palsy.
b. Meningeal irritation.
c. Lower motor neuron lesion.
d. Upper motor neuron lesion.


ANS: B
Opisthotonos is a form of spasm in which the head is arched back, and a stiffness of the neck and an extension of the arms and legs are observed. Opisthotonus occurs with meningeal or brainstem irritation

Nursing

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During an examination, the nurse finds that a patient's left temporal artery is tortuous and feels hardened and tender, compared with the right temporal artery. The nurse suspects which condition?

a. Crepitation b. Mastoiditis c. Temporal arteritis d. Bell palsy

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As a result of a client's extreme anxiety and concern about delusional and hallucinatory phenomena, the nurse plans care because the client is at risk for which of the following? (Select all that apply.)

1. High nighttime levels of melatonin 2. Circadian cycle disruption 3. REM rebound 4. Reduced REM sleep 5. Great difficulty getting to sleep

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A nurse is performing an otoscopic exam on a school-age child. Which direction should the nurse pull the pinna for this age of child?

a. Up and back b. Down and back c. Straight back d. Straight up

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The client asks the nurse what she should do about a skin lesion she is very worried about. The nurse suggests the client should notify her physician for a diagnosis. The client is relieved and states she will make an appointment

This type of activity is considered: A) coping. B) buffering. C) appraisal. D) secondary appraisal.

Nursing