Physiological Adaptation Q 109
The client with suspected meningitis is admitted to the unit. The doctor is performing an assessment to determine meningeal irritation and spinal nerve root inflammation. A positive Kernig’s sign is charted if the nurse notes:
A. Pain on flexion of the hip and knee
B. Nuchal rigidity on flexion of the neck
C. Pain when the head is turned to the left side
D. Dizziness when changing positions
Correct Answer: A. Pain on flexion of the hip and knee
Kernig’s sign is positive if pain occurs on flexion of the hip and knee. Kernig’s sign is one of the physically demonstrable symptoms of meningitis. Severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees.
Option B: The Brudzinski reflex is positive if pain occurs on flexion of the head and neck onto the chest. Brudzinski’s sign is one of the physically demonstrable symptoms of meningitis. Severe neck stiffness causes a patient’s hips and knees to flex when the neck is flexed. Brudzinski’s sign is used to diagnose meningitis.
Option C: A tension headache may cause pain on the left side and behind the eyes, and may be linked to stress. Tension headaches account for up to 42 percent of headaches worldwide. They may occur on one side so could be the cause of a headache on the left side.
Option D: Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of vertigo — the sudden sensation that you’re spinning or that the inside of your head is spinning. BPPV causes brief episodes of mild to intense dizziness. It is usually triggered by specific changes in the head’s position. This might occur when one tips their head up or down, when the client lies down, or when he turns over or sits up in bed.