What technique should the nurse use to elicit the Brudzinski reflex in a client being assessed for meningitis?
A. Instruct the client to hold both hands back to back while flexing the wrists 90 de-grees.
B. Gently flex the client's head and neck onto the chest and observe for flexion of the hips and knees.
C. Have the client stand with feet and knees together and eyes closed. Observe for swaying.
D. Flex the client's leg at the hip, bringing the knee to a 90-degree angle, extend the knee, and observe the client for hamstring muscle pain or spasm.
B
A positive Brudzinski's reflex is indicative of meningeal irritation. Flexing the client's head to the chest places tension on the meninges around the spinal cord.
You might also like to view...
A gardener sustained a deep laceration while working and requires sutures
The patient is asked about the date of her last tetanus shot which, she tells the nurse, is over 10 years ago. Based on this information the patient will receive a tetanus immunization. The tetanus injection will allow for the release of what? A) An antibody B) An antigen C) A bacteria D) A virus
In an older adult who is usually very alert, disorientation may be a sign of
a. iron deficiency. b. malnutrition. c. edema. d. dehydration.
The nurse is developing a plan of care for a client with a diagnosis of ineffective coping. An intervention to help the client develop insight would include:
A) Having the client identify how the illness has affected the client's life. B) Providing the client with a list of community resources. C) Identifying adaptive coping mechanisms. D) Discussing ways of dealing with stress.
If heavy bleeding is NOT stopped, the body goes into shock
True False