Author Question: The nurse is assessing the client and anticipates which of the following as early signs of ... (Read 32 times)

Anajune7 · **on:** Jul 22, 2018

The nurse is assessing the client and anticipates which of the following as early signs of meningitis? (Select all that apply.)

1. Chills
2. Seizures and paralysis
3. Nuchal rigidity
4. Positive Kernig's sign
5. Negative Brudzinski sign

Question 2

When a nurse delegates a treatment to be performed by other personnel

a. the hospital is ultimately responsible for the treatment
b. that other person documents the patient's response to treatment
c. the nurse is responsible for ensuring that the treatment was completed according to standards of care
d. that other person is ultimately responsible for the patient's response to treatment

jesse.fleming · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

3. Nuchal rigidity
4. Positive Kernig's sign

Rationale:
Nuchal rigidity, or pain when flexing the neck, is a classic symptom of meningitis resulting from inflammation of the meninges. Positive Kernig's sign is found when the client cannot extend the leg when the hip is flexed at a 90 angle. Brudzinski sign, or neck flexion causing the knees and hips to flex, would also be positive. Seizures, paralysis, fever, and chills would all be late signs of meningitis.

Answer to Question 2

C
The registered nurse is held accountable to delegate only such care that can safely be done by the other individual and would be performed with the same level of competency and respect for state laws and regulations as would be evident in the nurse's performance of this care. Although a nurse might delegate certain tasks to other personnel, it is still the nurse's responsibility to ensure that the task was completed according to standards of care and to note the response of the patient in order to evaluate progress toward expected outcomes.