The nurse is preparing to conduct an assessment of a patient's ...

[dalyningkenk]

The nurse is preparing to conduct an assessment of a patient's neurological status. What is the nurse assessing for in this diagram?
 
  1. Kernig sign
  2. Babinski reflex
  3. Brudzinski sign
  4. decorticate posturing

Question 2

The nurse is assessing the patient using the technique shown. Which finding should the nurse consider normal?
 
  1. pain only at the hip during flexion
  2. resistance in the hip joint
  3. a clicking sound in the knee upon flexion
  4. no pain or resistance in either hip or knee joint

[lin77x]

Answer to Question 1

Correct Answer: 3
To test for the Brudzinski sign, the nurse flexes the patient's head to the chest with the patient supine. If pain, resistance, or flexion of the hips or knees occurs, this indicates meningeal irritation. Kernig sign is positive when the leg is bent at the hip and knee at 90-degree angles and subsequent extension is painful. This may be an indication of subarachnoid hemorrhage or meningitis. The Babinski reflex occurs when the big toe moves toward the top of the foot and the other toes fan out after the sole of the foot has been firmly stroked. This reflex is normal in younger children but abnormal after the age of 2. In decorticate posturing the upper arms are close to the sides; the elbows, wrists, and fingers are flexed; the legs are extended with internal rotation; and the feet are plantar flexed.

Answer to Question 2

Correct Answer: 4
This test assesses for Kernig sign. The patient should feel no pain or resistance during this maneuver. Pain in the hip, resistance in the hip, and a clicking sound in the knee are not normal.