a nurse is assessing a client who has meningitis the nurse should identify which of the following findings as a positive kernigs sign
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Nursing Elites

ATI RN

ATI Capstone Adult Medical Surgical Assessment 1

1. A nurse is assessing a client who has meningitis. The nurse should identify which of the following findings as a positive Kernig's sign?

Correct answer: B

Rationale: A positive Kernig's sign is identified when a client is unable to extend their leg completely without pain after hip flexion. This finding suggests meningeal irritation. Choices A, C, and D do not describe Kernig's sign. Choice A describes a normal plantar reflex, Choice C refers to coordination deficits, and Choice D indicates neck pain and stiffness, which are not related to Kernig's sign.

2. What is the priority dietary modification for a patient with pre-dialysis end-stage kidney disease?

Correct answer: A

Rationale: The correct answer is A: Limit phosphorus intake to 700 mg/day. In patients with pre-dialysis end-stage kidney disease, restricting phosphorus intake is crucial to manage their condition. Excessive phosphorus can lead to mineral and bone disorders, which are common in kidney disease. Choice B, increasing potassium intake, is not the priority and can be harmful as kidney disease often leads to hyperkalemia. Choice C, eating three large meals per day, is not recommended as smaller, frequent meals are usually better tolerated. Choice D, restricting protein intake to 1 g/kg/day, is important in later stages of kidney disease but is not the priority at the pre-dialysis stage.

3. What are the expected ECG changes in hypokalemia?

Correct answer: A

Rationale: Flattened T waves are the most common ECG change seen in patients with hypokalemia. Hypokalemia leads to a decrease in serum potassium levels, affecting the repolarization phase of the cardiac action potential. This results in T wave flattening or inversion. ST elevation is typically seen in conditions like myocardial infarction, not in hypokalemia. Wide QRS complex is more associated with hyperkalemia than hypokalemia. Tall T waves are often seen in hyperkalemia, not hypokalemia.

4. A patient diagnosed with hypokalemia is at risk for which condition?

Correct answer: A

Rationale: Patients diagnosed with hypokalemia are at risk for cardiac dysrhythmias due to low potassium levels. Hypokalemia can lead to abnormalities in the electrical conduction system of the heart, potentially causing irregular heart rhythms. Muscle weakness (Choice B) is a symptom commonly associated with hypokalemia, but the question asks about conditions the patient is at risk for, not specific symptoms. Seizures (Choice C) are not typically associated with hypokalemia; they are more commonly linked with conditions such as epilepsy. Bradycardia (Choice D) refers to a slow heart rate, which is not a typical risk associated with hypokalemia; instead, tachycardia (fast heart rate) is more commonly observed in patients with low potassium levels.

5. What is the correct action when a patient reports cramping during enema administration?

Correct answer: A

Rationale: The correct action to take when a patient reports cramping during enema administration is to lower the height of the solution container. Lowering the height reduces the pressure and speed of the solution entering the rectum, alleviating cramping. Increasing the flow of the enema solution (Choice B) can worsen the discomfort. Stopping the procedure and removing the tubing (Choice C) is not necessary unless there are severe complications. Continuing the enema at a slower rate (Choice D) may not effectively address the immediate cramping issue and could still cause discomfort to the patient.

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