a nurse is assessing a client who has meningitis the nurse should identify which of the following findings as a positive kernigs sign

ATI RN

ATI Capstone Adult Medical Surgical Assessment 1

1. A nurse is assessing a client who has meningitis. The nurse should identify which of the following findings as a positive Kernig's sign?

A. After stroking the lateral area of the foot, the client's toes contract and draw together
B. After hip flexion, the client is unable to extend their leg completely without pain
C. The client's voluntary movement is not coordinated
D. The client reports pain and stiffness when flexing their neck

Correct answer: B

Rationale: A positive Kernig's sign is identified when a client is unable to extend their leg completely without pain after hip flexion. This finding suggests meningeal irritation. Choices A, C, and D do not describe Kernig's sign. Choice A describes a normal plantar reflex, Choice C refers to coordination deficits, and Choice D indicates neck pain and stiffness, which are not related to Kernig's sign.

2. What is the priority action if a patient experiences abdominal cramping during enema administration?

A. Lower the height of the solution container
B. Increase the flow of the enema solution
C. Stop the procedure and remove the tubing
D. Continue the enema at a slower rate

Correct answer: A

Rationale: During enema administration, if a patient experiences abdominal cramping, the priority action is to lower the height of the solution container. This adjustment can help relieve abdominal cramping by reducing the flow rate of the enema, making it more comfortable for the patient. Increasing the flow of the enema solution (Choice B) can exacerbate the cramping. Stopping the procedure and removing the tubing (Choice C) may be necessary in some cases of severe discomfort or complications, but adjusting the height of the solution container should be the initial response. Continuing the enema at a slower rate (Choice D) may not address the immediate need to alleviate the cramping.

3. What are the expected signs in a patient with compartment syndrome?

A. Unrelieved pain, pallor, and pulselessness
B. Fever and infection
C. Localized redness and swelling
D. Loss of sensation in the affected area

Correct answer: A

Rationale: In a patient with compartment syndrome, the classic signs include unrelieved pain, pallor, and pulselessness. These signs indicate compromised circulation and neurovascular function in the affected compartment. Fever and infection (Choice B) are not typical signs of compartment syndrome. Localized redness and swelling (Choice C) can be seen in other conditions like cellulitis but are not specific to compartment syndrome. Loss of sensation in the affected area (Choice D) may occur in some cases but is not as specific or consistent as unrelieved pain, pallor, and pulselessness in diagnosing compartment syndrome.

4. What are the expected signs of increased intracranial pressure (IICP)?

A. Restlessness, confusion, irritability
B. Severe headache and confusion
C. Elevated blood pressure and bradycardia
D. Bradycardia and altered pupil response

Correct answer: A

Rationale: The correct answer is A: Restlessness, confusion, irritability. These are early signs of increased intracranial pressure (IICP) and require prompt intervention. Restlessness, confusion, and irritability are indicative of the brain's attempt to compensate for the rising pressure. Choice B is incorrect because severe headache alone is not specific to IICP and can be present in various conditions. Choice C is incorrect because elevated blood pressure is not a common sign of IICP; instead, hypertension may be present in the compensatory stage. Choice D is incorrect as bradycardia and altered pupil response are signs of advanced IICP, not early signs. Monitoring and recognizing these early signs are crucial for timely intervention and preventing further complications.

5. What does continuous bubbling in the water seal chamber of a chest tube indicate?

A. An air leak
B. Normal chest tube function
C. A blockage in the chest tube
D. A malfunction in the drainage system

Correct answer: A

Rationale: Continuous bubbling in the water seal chamber of a chest tube indicates an air leak. This bubbling occurs when air leaks from the patient's pleural space into the chest tube system. It is essential to address this issue promptly to prevent complications like a pneumothorax. Choices B, C, and D are incorrect because continuous bubbling in the water seal chamber is not indicative of normal chest tube function, a blockage in the chest tube, or a malfunction in the drainage system.