Question: The nurse is evaluating the status of the client who had a craniotomy 3 days ago. The nurse would suspect that the client is developing meningitis as a complication of surgery if the client exhibits:
1. A negative Kernig sign
2. Absence of nuchal rigidity
3. A positive Brudzinski sign
4. A Glasgow Coma Scale score of 15
Rationale: Signs of meningeal irritation compatible with meningitis include nuchal rigidity, a positive Brudzinski sign, and positive Kernig 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: Use the process of elimination, focusing on the client's diagnosis, meningitis. You can eliminate options 1, 2, and 4 because they are normal findings. Review the signs of meningitis if you had difficulty with this question.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process--Assessment
Content Area: Adult Health--Neurological
Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed., p 1835-1836). St. Louis: Saunders
This week’s NCLEX exam practice question came from:
Silvestri: Saunders Comprehensive Review for the NCLEX-RN Examination, 5th edition, Chapter 66, pg 961, question 813
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