A 76-year-old woman arrives at the emergency department by ambulance with a possible stroke. Vital signs are pulse 90, blood pressure 150/100, respirations 20. Thirty minutes later, vital signs are pulse 78, blood pressure 170/90, respirations 24 and irregular. The nurse should take which action at this time?

Check the client's phenytoin (Dilantin) level.

Get an order to decrease the rate of IV fluids.

Ask the woman to describe how she's feeling.

Offer the client clear liquids to prevent dehydration.

Answer and Explanation

The Correct Answer is C

A. Check the client's phenytoin (Dilantin) level: Checking the phenytoin level would not be relevant in this situation as the client's presentation suggests a possible stroke, not related to phenytoin therapy.

B. Get an order to decrease the rate of IV fluids: While managing fluid balance is important, there is insufficient information to warrant decreasing IV fluids at this time. It's essential to assess the client's overall condition and consult with the healthcare provider before making changes to IV fluid administration.

C. Ask the woman to describe how she's feeling: Assessing the client's symptoms and response to treatment is crucial for monitoring her condition and guiding further interventions, especially in
the context of a possible stroke.

D. Offer the client clear liquids to prevent dehydration: While maintaining hydration is
important, offering clear liquids would not address the potential stroke or irregular respirations. Assessment and intervention related to the client's neurological status and respiratory function take precedence.

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Correct Answer is C

Explanation

A. Transfer the patient to radiology: Lumbar punctures are typically performed at the bedside in the patient's room or in a procedure room, not in radiology.
B. Enforce NPO status for 4 hours: NPO (nothing by mouth) status is not typically required before a lumbar puncture unless specifically ordered by the healthcare provider for a particular reason.
C. Help the patient to a lateral position: Before a lumbar puncture, the patient should be placed in a lateral recumbent position (usually on their side with knees flexed towards the chest) to facilitate the procedure and minimize the risk of complications such as post-dural puncture headache.
D. Administer a sedative medication: Sedative medications are not routinely administered before a lumbar puncture, as they can alter the patient's level of consciousness and interfere with neurological assessment during and after the procedure.

Correct Answer is []

Explanation

The client is most likely experiencing meningitis based on the following clinical manifestations:

Symptoms: The client presents with a 2-day history of lethargy, nausea, vomiting, anorexia, headache, general muscle aches, diarrhea, abdominal pain, sore throat, sensitivity to light, and intermittent nystagmus. These symptoms are consistent with the classic signs of meningitis, including headache, nausea, vomiting, photophobia, and altered mental status.
Physical Examination Findings: The physical examination reveals a fever (temperature of 38.9°C or 102°F), elevated heart rate (118/min), and signs of meningeal irritation such as neck stiffness (not directly mentioned but implied by headache and sensitivity to light). Additionally, a pinpoint, red, macular rash on the upper chest may indicate petechiae, which can be seen in meningococcal meningitis.

Given the suspicion of meningitis, the nurse should take the following actions:

Implement seizure precautions: Meningitis can lead to increased intracranial pressure and neurological complications, including seizures. Implementing seizure precautions involves ensuring the client's safety by padding the side rails of the bed, keeping the bed in a low position, and providing close observation.
Dim the lights in the client’s room: The client reports sensitivity to light, which is a common symptom of meningitis due to meningeal irritation. Dimming the lights can help reduce discomfort and photophobia in the client.

Parameters to Monitor:

Neurologic status: Monitoring the client's neurologic status is crucial for assessing the progression of meningitis and detecting any neurological deterioration, such as changes in level of consciousness, motor deficits, or signs of increased intracranial pressure.
Temperature: Monitoring the client's temperature is essential to assess for fever spikes or trends, which can indicate the severity of the infection and response to treatment.

Persistent or worsening fever may suggest inadequate treatment or complications such as abscess formation.

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Naxlex Comprehensive Predictor Exams

A patient with suspected meningitis is scheduled for a lumbar puncture. What action should the nurse take before the procedure?

Correct Answer is C

Explanation

Correct Answer is []

Explanation

Which problem should the nurse expect for a patient who has a positive Romberg test result?

A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following medication would the nurse anticipate to administer?

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

The nurse anticipates that the client presenting with increased intracranial pressure would most likely exhibit which set of vital signs?

A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic bladder. Which action should the nurse include in the plan of care?

A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first?

Which intervention should the nurse include in the plan of care for a patient with new right- sided homonymous hemianopsia after a stroke?

A nurse is caring for a client who reports a throbbing headache and hypotension after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache?