Author Question: A patient in the supine position with the head flexed to the chest is not experiencing any pain, ... (Read 109 times)

berenicecastro · **on:** Jun 25, 2018

A patient in the supine position with the head flexed to the chest is not experiencing any pain, resistance, or flexion of the hips or knees. What is the nurse assessing in this patient?

1. doll's-eyes reflex
2. Brudzinski sign
3. Babinski reflex
4. Kernig sign

Question 2

While assisting with a lumbar puncture, the nurse determines that a patient's cerebrospinal (CSF) fluid is normal. What did the nurse assess to make this clinical decision?

1. The CSF is yellow, without sediment.
2. The CSF is tinged with blood but has no sediment.
3. The CSF is clear and colorless.
4. The CSF is pink, without sediment.

iman · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer: 2
The Brudzinski sign is elicited by placing the patient in a supine position and flexing the neck toward the chest. A positive result would be noted if the patient has pain or flexes the hip or knees; it indicates meningeal irritation. Testing for the Babinski reflex involves gently scraping the sole of the foot with a blunt object. To assess for Kernig sign, the nurse has the patient, in the supine position, flex the knees and hips, then straighten the knee. Assessing the direction in which the eyes move when the head is turned tests for the doll's-eyes reflex.

Answer to Question 2

Correct Answer: 3
Normal CSF is clear and colorless, not yellow, blood-tinged, or pink.