# A nurse is assessing a 28-year-old patient admitted with suspected viral encephalitis. Which assessment finding would be the most significant indicator requiring immediate intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541225 > language: ko > subject: Adult Health ## 문제 A nurse is assessing a 28-year-old patient admitted with suspected viral encephalitis. Which assessment finding would be the most significant indicator requiring immediate intervention? ## 보기 1. Nuchal rigidity with positive Kernig's and Brudzinski's signs **✔ 정답** 2. Temperature of 101.5°F with chills and body aches 3. Photophobia with mild nausea and dizziness 4. Severe headache rated 8/10 with neck stiffness **정답: 1** ## 해설 Nuchal rigidity with positive Kernig's and Brudzinski's signs indicates meningeal irritation and increased intracranial pressure, which are critical findings requiring immediate intervention to prevent brain herniation. Other options (fever, photophobia, headache) are common in encephalitis but less urgent. ## 심화 해설 Clinical Context and Priority Setting This question tests your ability to recognize the most critical clinical finding in a patient with suspected viral encephalitis and to prioritize interventions based on the risk of life-threatening deterioration. Viral encephalitis involves inflammation of the brain parenchyma, often accompanied by meningeal inflammation (meningoencephalitis). The clinical spectrum ranges from mild, self-limiting symptoms to severe neurological compromise and death. Your primary role as a nurse is to identify findings that signal a progression from meningitis to encephalitis or indicate rising intracranial pressure (ICP), as these require immediate escalation of care. Analysis of Assessment Findings Let's examine each option through the lens of pathophysiology and clinical urgency: - Option 1: Nuchal rigidity with positive Kernig's and Brudzinski's signs. These are classic signs of meningeal irritation. The meninges, which envelop the brain and spinal cord, become inflamed due to the viral infection. Nuchal rigidity (stiff neck) results from reflex muscle spasm to prevent stretching of the inflamed meninges. A positive Kernig's sign (inability to fully extend the leg when the hip is flexed) and Brudzinski's sign (involuntary hip and knee flexion when the neck is flexed) are objective indicators of this same irritation. While these signs confirm central nervous system (CNS) involvement, they are *diagnostic* indicators of meningitis and do not, by themselves, signal an immediate, life-threatening change in neurological status. They are expected findings in the setting of suspected viral CNS infection. - Option 2: Temperature of 101.5°F with chills and body aches. Fever is a hallmark of the body's immune response to viral pathogens, including enteroviruses, which are the most common cause of viral meningitis [2]. Systemic symptoms like chills and myalgia (body aches) are part of the prodromal or acute phase of a viral illness. The cited literature confirms that typical presentations of viral CNS infections include fever and headache [1,2]. While uncomfortable and requiring symptomatic management, a fever of this degree in an adult is not the most critical finding. It does not directly indicate a threat to airway, breathing, or cerebral perfusion. - Option 3: Photophobia with mild nausea and dizziness. Photophobia (sensitivity to light) and nausea are common symptoms associated with both meningeal irritation and increased ICP. Dizziness can be a non-specific symptom of the systemic viral illness or related to vestibular involvement. These are supportive symptoms that contribute to the clinical picture of meningitis but are not the highest priority. They do not represent an acute neurological crisis requiring immediate intervention beyond supportive care and ongoing monitoring. - Option 4: Severe headache rated 8/10 with neck stiffness. A severe headache is a cardinal symptom of both meningitis and encephalitis, often caused by inflammation and stretching of pain-sensitive structures in the meninges and blood vessels. Neck stiffness, as mentioned, is a sign of meningeal irritation. While the pain intensity is high and warrants prompt analgesic intervention, this combination of symptoms is still an expected manifestation of the disease process. It does not provide a specific warning of an imminent herniation event or loss of airway protective reflexes, which are the most urgent concerns in encephalitis. Why Option 1 is the Most Significant Indicator The question asks for the finding that is the *most significant indicator requiring immediate intervention*. In the context of suspected viral encephalitis, the critical pivot point is the transition from isolated meningeal signs to signs of direct brain parenchymal involvement. The presence of unequivocal, objective meningeal signs (nuchal rigidity, positive Kernig's, positive Brudzinski's) is the strongest clinical evidence that the inflammatory process is well-established within the CNS. This finding mandates immediate preparation for diagnostic lumbar puncture (LP) and initiation of empiric therapy while awaiting results, as it confirms the syndrome of meningitis/encephalitis. Early recognition and LP are essential to avoid misdiagnosis [1]. The other options describe symptoms that, while part of the clinical picture, are more subjective or systemic and do not carry the same weight in definitively confirming a CNS emergency. The nurse must recognize that these physical exam findings are the most concrete indicators of a process that can rapidly deteriorate, thus requiring the most urgent reporting and intervention. References (research sources) - [1]An Atypical Presentation of Enteroviral Meningitis in an Immunocompetent Adult Man.Research articleGreer K, Brutti J, Kowobari T, Del Pilar Bonilla L. (2025) · DOI: 10.7759/cureus.96231 - [2]Etiology, Clinical Phenotypes, Epidemiological Correlates, Laboratory Biomarkers and Diagnostic Challenges of Pediatric Viral Meningitis: Descriptive Review.Research articleAl-Qahtani SM, Shati AA, Alqahtani YA, Ali AS. (2022) · DOI: 10.3389/fped.2022.923125 ## 임상 시나리오 Meningeal Signs in Suspected EncephalitisDifferentiating Irritation from Life-Threatening Deterioration Nuchal rigidity, Kernig's sign, and Brudzinski's sign confirm meningeal irritation but do not independently indicate rising intracranial pressure (ICP) or impending herniation. They require ongoing monitoring for progression to encephalopathy. CautionThe most significant immediate intervention triggers are a declining level of consciousness, Cushing's triad (bradycardia, hypertension, irregular respirations), or pupillary changes, which signal brainstem compromise. Do not mistake static meningeal signs for these dynamic, life-threatening changes. ## 핵심 개념 - **Nuchal Rigidity** — Neck stiffness and pain on flexion due to meningeal inflammation, a classic sign of meningitis. - **Kernig's Sign** — A clinical sign of meningeal irritation where the patient resists full extension of the leg when the hip is flexed at 90 degrees. - **Brudzinski's Sign** — A sign of meningeal irritation where passive flexion of the neck causes involuntary flexion of the hips and knees. - **Viral Encephalitis** — Inflammation of the brain parenchyma, often caused by viral infection, leading to neurological dysfunction. - **Meningismus** — The triad of nuchal rigidity, photophobia, and headache, indicating irritation of the meninges. ## 같은 주제 문제 - [A nurse is assessing a 45-year-old patient admitted with suspected viral encephalitis. 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