Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Which of the following describes the correct procedure for testing for Kernig's sign?
A. Rotate the neck to one side while observing the eyes moving to the opposite side.
Rotating the neck to one side while observing the eyes moving to the opposite side is a procedure for testing for oculocephalic reflex or doll's eye phenomenon, which indicates brainstem function.
B. Passively elevate the leg with extended knee while observing for pain, resistance, or flexion.
This is the correct answer. Kernig's sign is a clinical sign that indicates meningitis, which is an inflammation of the membranes that cover the brain and spinal cord. To test for Kernig's sign, the nurse should flex the patient's hip to 90 degrees and then attempt to extend the knee. A positive Kernig's sign is when the patient experiences pain in the lower back or hamstring, resists knee extension, or involuntarily flexes the opposite leg.
C. Stroke the lateral aspect of the sole of the patient's foot and observe for dorsiflexion of the big toe.
Stroking the lateral aspect of the sole of the patient's foot and observing for dorsiflexion of the big toe is a procedure for testing for Babinski's sign, which indicates upper motor neuron lesion or damage.
D. Passively flex the patient's neck forward and observe for hip and knee flexion.
Passively flexing the patient's neck forward and observing for hip and knee flexion is a procedure for testing for Brudzinski's sign, which also indicates meningitis.
This question is an excerpt from Nurse Dive's nursing test bank - Interprofessional Care of the Client and Family Across the Lifespan II Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale: Rotating the neck to one side while observing the eyes moving to the opposite side is a procedure for testing for oculocephalic reflex or doll's eye
phenomenon, which indicates brainstem function.
Choice B rationale: This is the correct answer. Kernig's sign is a clinical sign that indicates meningitis, which is an inflammation of the membranes that cover the brain and spinal cord. To test for Kernig's sign, the nurse should flex the patient's hip to 90 degrees and then attempt to extend the knee. A positive Kernig's sign is when the patient
experiences pain in the lower back or hamstring, resists knee extension, or involuntarily flexes the opposite leg.
Choice C rationale: Stroking the lateral aspect of the sole of the patient's foot and observing for dorsiflexion of the big toe is a procedure for testing for Babinski's sign, which indicates upper motor neuron lesion or damage.
Choice D rationale: Passively flexing the patient's neck forward and observing for hip and knee flexion is a procedure for testing for Brudzinski's sign, which also indicates meningitis.
 |
Similar Questions
A client comes to the outpatient department complaining of vaginal discharge, dysuria, and genital irritation. Suspecting a sexually transmitted disease (STD), Dr. Smith orders diagnostic tests of the vaginal discharge. Which STD must be reported to the public health department?
A. Human papillomavirus infection
HPV is a sexually transmitted infection but must not necessarily be reported to the public health department.
B. Genital herpes
Genital herpes should not be reported to the public health department.
C. Gonorrhea
Gonorrhea is a reportable disease, meaning that health care providers must notify the public health department of any confirmed cases. This helps to prevent the spread of the infection and provide treatment and counseling to the affected individuals and their partners.
D. Infectious mononucleosis
Infectious mononucleosis should not be reported to the public health department.
Full Explanation
Choice A rationale: HPV is a sexually transmitted infection but must not necessarily be reported to the public health department.
Choice B rationale: Genital herpes should not be reported to the public health department.
Choice C rationale: Gonorrhea is a reportable disease, meaning that health care providers must notify the public health department of any confirmed cases. This helps to prevent the spread of the infection and provide treatment and counseling to the affected individuals and their partners.
Choice D rationale: Infectious mononucleosis should not be reported to the public health department.
Upon physical examination, the nurse detects abdominal tenderness, increased bowel sounds accompanied by signs of borborygmi, abdominal distension, and tympany on percussion. Which diagnostic test will confirm Crohn's disease in the client?
A. an exam used to detect and help your doctor view the inside of your body without having to make an incision or invasion. This can help them diagnose, monitor, and treat many medical conditions
This is a general description of an imaging test, such as an X-ray, ultrasound, or MRI, which can show the structure of the organs but not the mucosal lining.
B. an exam used to detect and help your doctor look for a range of disorders and conditions, screen for diseases and adjust treatments, measures and counts your blood cells.
This is a general description of a blood test, which can show signs of infection, inflammation, or anemia, but not the cause of these problems.
C. an exam used to detect and help your doctor view changes or abnormalities in the large intestine and rectum.
This exam is called a colonoscopy, which involves inserting a flexible tube with a camera and light into the anus and advancing it through the colon. A colonoscopy can reveal signs of inflammation, ulcers, bleeding, or narrowing of the intestinal wall that are characteristic of Crohn's disease. A biopsy can also be taken during the procedure to confirm the diagnosis.
D. an exam used to detect and help your doctor view for things cannot be seen with the naked eye, including red blood cells, white blood cells (or pus cells), bacteria (germs), or crystals.
This is a general description of a urine test, which can show signs of kidney problems, urinary tract infections, or dehydration, but not Crohn's disease.
Full Explanation
Choice A rationale: This is a general description of an imaging test, such as an X-ray, ultrasound, or MRI, which can show the structure of the organs but not the mucosal lining.
Choice B rationale: This is a general description of a blood test, which can show signs of infection, inflammation, or anemia, but not the cause of these problems.
Choice C rationale: This exam is called a colonoscopy, which involves inserting a flexible tube with a camera and light into the anus and advancing it through the colon. A colonoscopy can reveal signs of inflammation, ulcers, bleeding, or narrowing of the intestinal wall that are characteristic of Crohn's disease. A biopsy can also be taken during the procedure to confirm the diagnosis.
Choice D rationale: This is a general description of a urine test, which can show signs of kidney problems, urinary tract infections, or dehydration, but not Crohn's disease.
Your patient has complaints of severe right-sided flank pain, nausea, vomiting and restlessness. He appears slightly pale and is diaphoretic. Vital signs are BP 140/90 mmHg, Pulse 118 beats/min., respirations 33 breaths/minute, and temperature, 98.0F. Which subjective data supports a diagnosis of renal calculi?
A. History of mild flu symptoms last week.
This is not relevant to the current condition of the patient and does not support a diagnosis of renal calculi.
B. Dark-colored coffee-ground emesis.
This is a sign of upper gastrointestinal bleeding, which can have many causes such as peptic ulcer, gastritis or esophageal varices. It is not related to renal calculi or urinary tract problems.
C. Pain radiating to the right upper quadrant.
Renal calculi usually causes pain which usually radiates anteriorly to the lower abdomen, groin, labia, testicles or the perineum depending on the location of the stone.
D. Dark, scanty urine output.
This is a sign of hematuria, which is blood in the urine caused by the passage of renal calculi (kidney stones) through the urinary tract. Hematuria can also cause the urine to appear dark or brown in color.
Full Explanation
Choice A rationale: This is not relevant to the current condition of the patient and does not support a diagnosis of renal calculi.
Choice B rationale: This is a sign of upper gastrointestinal bleeding, which can have many causes such as peptic ulcer, gastritis or esophageal varices. It is not related to renal calculi or urinary tract problems.
Choice C rationale: Renal calculi usually causes pain which usually radiates anteriorly to the lower abdomen, groin, labia, testicles or the perineum depending on the location of the stone.
Choice D rationale: This is a sign of hematuria, which is blood in the urine caused by the passage of renal calculi (kidney stones) through the urinary tract. Hematuria can also cause the urine to appear dark or brown in color.