Page 2062 - Saunders Comprehensive Review For NCLEX-RN

seizure activity begins.
Test-Taking Strategy: Focus on the subject, seizure precautions. Evaluate this
question from the perspective of causing possible harm. No harm can come to the
client from any of the options except for placing the bed in the high position and
using a tongue blade.
Level of Cognitive Ability: Analyzing
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process—Planning
Content Area: Adult Health: Neurological
Health Problem: Adult Health: Neurological: Seizure disorder/epilepsy
Priority Concepts: Intracranial Regulation; Safety
Reference: Lewis et al. (2017), p. 1378.

721. Answer: 3

Rationale: Signs of meningeal irritation compatible with meningitis include
nuchal rigidity, a positive Brudzinski’s sign, and positive Kernig’s sign. Nuchal
rigidity is characterized by a stiff neck and soreness, which is especially noticeable
when the neck is flexed. Kernig’s sign is positive when the client feels pain and
spasm of the hamstring muscles when the leg is fully flexed at the knee and hip.
Brudzinski’s sign is positive when the client flexes the hips and knees in response to
the nurse gently flexing the head and neck onto the chest. A Glasgow Coma Scale
score of 15 is a perfect score and indicates that the client is awake and alert, with no
neurological deficits.
Test-Taking Strategy: Focus on the subject, a client’s diagnosis of meningitis. You
can eliminate options 1, 2, and 4 because they are comparable or alike and are
normal findings.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Adult Health: Neurological
Health Problem: Adult Health: Neurological: Inflammation/infections
Priority Concepts: Clinical Judgment; Intracranial Regulation
Reference: Heuther & McCance (2017), pp. 408-409.

722. Answer: 2

Rationale: The halo device alters balance and can cause fatigue because of its
weight. The client should cleanse the skin daily under the vest to protect the skin
from ulceration and should avoid the use of powder or lotions. The liner should be
changed if odor becomes a problem. The client should have food cut into small
pieces to facilitate chewing and use a straw for drinking. Pin care is done as
instructed. The client cannot drive at all, because the device impairs the range of
vision.
Test-Taking Strategy: Note the strategic words, needs further clarification. These
words indicate a negative event query and ask you to select an option that is
incorrect. Visualize this device to answer correctly. The inability to turn the head

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