Difficulty: Medium
Average Score: 79%
Full-length
An 8-year-old boy is brought to the physicianÔÇÖs office by his mother. The mother is concerned because the boy has a fever, vomited twice, and slept all day yesterday with the curtains closed. The boy complains of headache, nausea, and has a temperature of 103┬░F (39.3┬░C). The nurse observes the boy has a petechial rash on the trunk of his body. Which of the following assessments would be MOST important for the nurse to perform?
Correct answer
C
Rationale
Fever, headache, nausea, and petechial rash suggest meningitis; flexing the neck (BrudzinskiÔÇÖs sign) assesses meningeal irritation, a priority. Options A, B, and D are less relevant: hand squeeze is nonspecific, BabinskiÔÇÖs sign is not indicated, and RombergÔÇÖs sign assesses balance.