The nurse is admitting a client with suspected meningitis and ...

[laurencescou]

The nurse is admitting a client with suspected meningitis and notes a positive Brudzinski sign has been noted in the history and physical. Which clinical manifestation would validate this assessment finding?
 
  1. Seizure activity.
  2. Neck pain and stiffness.
  3. Flexion of the legs and thighs.
  4. Neck extension.

Question 2

The nurse is caring for a client experiencing vertigo and plans to perform the Romberg test during the assessment. Which instruction from the nurse regarding this test is the most appropriate?
 
  1. Touch your finger to your nose, alternating hands.
  2. Walk across the room by placing one foot in front of the other, heel to toes.
  3. Walk on your toes, then on your heels, then on your toes again.
  4. Stand with your feet together, arms at sides, and eyes open.

[adammoses97]

Answer to Question 1

Correct Answer: 3
Brudzinski sign is assessed in clients suspected of having meningitis. To assess for this sign the client is placed in a supine position and assisted to flex the neck. In a positive test the legs and thighs will also flex. Seizure activity may be seen in meningitis but seizure activity does not constitute a positive Brudzinski sign. Neck pain and stiffness may be noted with meningitis but this is referred to as nuchal rigidity. It does not constitute a positive Brudzinski sign. Neck extension is not associated with a positive Brudzinski sign.

Answer to Question 2

Correct Answer: 4
The Romberg test is used to assess coordination and equilibrium. During the test the client is asked to stand with feet together, arms at sides, and eyes open. As the test progresses the client is asked to close her eyes. The amount of swaying done by the client once the eyes are closed is observed. Walking across the room by placing one foot in front of the other, heel to toes, describes tandem walking, which is used to observe gait. Posture is assessed by asking the client to walk on the toes, then on the heels. Touching the finger to the nose with alternating hands is referred to as the finger-to-nose test and is used to assess coordination and equilibrium, but is not the same as the Romberg test.

[laurencescou]

Excellent

[robbielu01]

TYSM