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The patient is supine and the head is flexed to the chest without pain, resistance, or flexion of the hips or knees. The nurse is observing for which finding?1. Doll’s eyes reflex2. Brudzinski sign3. Babinski reflex4. Kernig’s signCorrect Answer: Rationale 1: In the doll’s eyes reflex, the eyes move in the opposite direction in which the head is turned.Rationale 2: The Brudzinski sign is elicited by placing the patient in a supine position and flexing the neck toward the chest. A positive result would be noted if the patient has pain or flexes the hip or knees in response to the neck flexion. A positive response indicates meningeal irritation.Rationale 3: The Babinski reflex is the extensor plantar response. An abnormal response is dorsiflexion of the big toe and often a fanning of the other toes. Rationale 4: To assess for Kernig’s sign, the patient, in the supine position, flexes the hip and extends the leg. Bilateral pain in the hamstring area that prevents straightening of the leg is a positive sign of meningitis.2Global Rationale: Cognitive Level: ApplyingClient Need: Physiological IntegrityClient Need Sub: Physiological AdaptationNursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 21-4Question 18Type: MCSAWhich neurologic assessment is being performed in the exhibit?
3Global Rationale: Cognitive Level: ApplyingClient Need: Physiological IntegrityClient Need Sub: Physiological AdaptationNursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 21-4Question 19Type: MCSAThe nurse is assessing the patient using the technique shown. What is considered a normal finding using this technique?4