A client presents to the health care clinic with a 3-day history of fever, chills, neck pain and stiffness, and headache. The nurse observes an elevated temperature of 102.5°F and pain with rotation of the head side to the side and decreased ability to flex the head forward. The nurse recognizes these findings as most likely the onset of what infectious process?
Bursitis
Meningitis
Spondylitis
Arthritis
The Correct Answer is B
A. Bursitis is the inflammation of the bursa, a small fluid-filled sac that reduces friction between bones and soft tissues. It typically causes localized pain and tenderness in the area of the bursa, often in the shoulders, elbows, or hips.
B. Meningitis is an infection or inflammation of the protective membranes covering the brain and spinal cord (the meninges). It often presents with symptoms such as fever, headache, neck stiffness, and photophobia. The neck stiffness, particularly difficulty flexing the head forward (nuchal rigidity), is a classic sign.
C. Spondylitis refers to inflammation of the spine. It can present with chronic back pain and stiffness but is typically associated with long-term symptoms rather than acute systemic symptoms like fever and chills. Conditions such as ankylosing spondylitis can cause chronic back pain and stiffness but are less likely to present with acute fever and headache.
D. Arthritis is inflammation of the joints and can cause pain, swelling, and stiffness in the affected joints. While arthritis can affect the neck (cervical spine arthritis), it typically does not present with systemic symptoms such as fever and chills unless there is an associated infection or inflammatory process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The sternoclavicular joint is where the sternum (breastbone) meets the clavicle (collarbone). It plays a role in the movement of the shoulder girdle but does not involve the jaw. Issues with this joint would typically present as shoulder or chest discomfort rather than problems with the jaw.
B. The temporomandibular joint is the joint where the mandible (lower jaw) meets the temporal bone of the skull, just in front of the ear. It is crucial for jaw movement, including opening, closing, and chewing. If a client feels that their jaws are "stuck," it is likely related to a problem with the TMJ. Common issues include TMJ disorders, which can cause pain, limited movement, or a sensation of the jaw being stuck.
C. The subtalar joint is located in the ankle, between the talus and calcaneus bones. It is involved in the movement of the foot, particularly in inversion and eversion. This joint is unrelated to jaw function, so problems here would affect the foot rather than the jaw.
D. The radioulnar joints are located in the forearm and involve the radius and ulna bones. These joints are responsible for the rotation of the forearm, such as turning the palm up or down. They do not relate to jaw movement or problems, so issues with these joints would affect the forearm or wrist rather than the jaw.
Correct Answer is ["A","B"]
Explanation
A. The verbal response is one of the three components of the Glasgow Coma Scale. It assesses the patient's ability to speak and respond appropriately to questions, indicating their level of consciousness. Responses are scored based on clarity, coherence, and relevance.
B. Motor response is another component of the Glasgow Coma Scale. It evaluates the patient’s ability to move in response to stimuli, including purposeful movements, localizing pain, or abnormal posturing. The motor response helps gauge the patient’s level of consciousness and neurological function.
C. Pupillary response refers to how the pupils react to light and changes in size. While important in neurological assessments, it is not one of the three components of the Glasgow Coma Scale. Pupillary response is assessed separately from the GCS but provides additional information about brain function and potential injury.
D. The gag reflex is a protective mechanism to prevent choking and is assessed by stimulating the back of the throat. It is not included in the Glasgow Coma Scale. The GCS focuses on eye opening, verbal response, and motor response rather than reflexes.
E. Eye opening is the third component of the Glasgow Coma Scale. It assesses the patient’s ability to open their eyes spontaneously or in response to stimuli. This component helps determine the level of consciousness and alertness.
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