A nurse in the emergency department (ED) is caring for an adolescent.
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Nurses' Notes
2 weeks ago, 1000:
16-year-old adolescent is brought to the emergency department (ED) due to a sudden onset of fever, headache, and reports of sensitivity to light. Guardian reports adolescent is refusing to eat or drink due to nausea.
Adolescent is lethargic and drowsy, arouses with verbal stimuli, but is irritable when aroused. Pupils equal, round, reactive to light, and accommodation (PERRLA). Hand grasps and pedal pulls and pushes are strong and equal bilaterally. Mucus membranes are dry and pink. Skin is very warm and dry to touch. Capillary refill is 2 seconds. Photophobia is present. Client reports headache pain as 10 on a scale of 0 to 10. Resists flexion of the neck. Cervical lymph nodes are without edema or tenderness. Breath sounds are clear and equal. Abdomen is soft, flat, bowel sounds are heard in all quadrants. Has small pinpoint purpuric rash bilaterally on lower extremities.
a sudden onset of fever, headache, and reports of sensitivity to light
Guardian reports adolescent is refusing to eat or drink due to nausea
Adolescent is lethargic and drowsy, arouses with verbal stimuli, but is irritable when aroused
Pupils equal, round, reactive to light, and accommodation (PERRLA)
Hand grasps and pedal pulls and pushes are strong and equal bilaterally
Photophobia is present
Client reports headache pain as 10 on a scale of 0 to 10
Resists flexion of the neck
Abdomen is soft, flat, bowel sounds are heard in all quadrants
Has small pinpoint purpuric rash bilaterally on lower extremities
The Correct Answer is ["A","C","F","G","H","J"]
Rationale for correct findings:
• Sudden onset of fever, headache, and sensitivity to light: These are hallmark symptoms of acute meningitis, where inflammation of the meninges causes severe headache and meningeal irritation. The fever reflects systemic infection, while photophobia results from irritation of the cranial nerves by meningeal inflammation.
• Adolescent is lethargic and drowsy, arouses with verbal stimuli, but irritable when aroused: Altered level of consciousness is a critical sign of central nervous system infection. Lethargy and irritability point toward worsening meningeal inflammation and rising ICP, both of which are dangerous and may precede seizures or coma.
• Photophobia is present: Photophobia occurs when inflammation of the meninges irritates cranial nerves III and IV, making light uncomfortable for the patient. This neurological sign is highly suggestive of meningitis, especially when combined with headache and fever.
• Client reports headache pain as 10/10: Severe headache is a defining symptom of meningitis and a consequence of meningeal irritation and increased ICP. Pain rated at the maximum level indicates intense distress and neurological involvement.
• Resists flexion of the neck: Nuchal rigidity is a classic clinical sign of meningeal irritation. Resistance to neck flexion reflects protective muscle spasm caused by inflamed meninges. This, alongside fever and altered mental status, is a key diagnostic triad for meningitis.
• Small pinpoint purpuric rash bilaterally on lower extremities: A purpuric rash is an ominous finding, particularly suggestive of meningococcemia, a life-threatening meningococcal infection. The rash indicates vascular damage and possible disseminated intravascular coagulation (DIC), both of which can progress rapidly to septic shock.
Rationale for incorrect findings:
• Pupils equal, round, reactive to light, and accommodation (PERRLA): This finding indicates that cranial nerves II and III are functioning normally, and there is no immediate sign of increased intracranial pressure compressing the optic nerve.
• Hand grasps and pedal pushes and pulls are strong and equal bilaterally: Strong and equal motor responses show that gross motor strength and neurological function in the extremities are intact. No focal weakness or paralysis is evident, meaning there is no localized neurological deficit.
• Abdomen is soft, flat, bowel sounds are heard in all quadrants; A soft abdomen with normal bowel sounds indicates intact gastrointestinal motility and no evidence of peritonitis, obstruction, or ileus. Despite nausea, there is no abdominal pathology complicating the case.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}
Explanation
Rationale:
• Weight-bearing ability on the affected leg: The adolescent was able to ambulate in the hall twice with good tolerance, which suggests improved mobility despite persistent tenderness. This indicates that pain and function are gradually improving.
• Temperature: The fever decreased from 38.8°C on Day 1 to 37.6°C on Day 2, showing resolution of the systemic response to infection. This suggests the antibiotic therapy is beginning to take effect.
• WBC count: The count rose from 14,000/mm³ to 15,000/mm³ in 24 hours, which reflects a persistent or worsening inflammatory and infectious process. This indicates the infection may not yet be under control.
• Wound assessment: The indurated area on the calf decreased in size from 6 x 6 cm on Day 1 to 5 x 5 cm on Day 2. A decrease in the size of the inflamed area indicates that the cellulitis is responding to treatment and resolving.
Correct Answer is ["A","B","E"]
Explanation
A. Rolling the adolescent onto their side is appropriate during seizure activity or altered consciousness to maintain an open airway and allow secretions or emesis to drain, reducing the risk of aspiration. This is part of standard seizure precaution care.
B. Not restraining the adolescent prevents musculoskeletal injury and does not interfere with involuntary seizure movements. Restraints can cause fractures, dislocations, or soft tissue injury and should be avoided during seizure activity.
C. Beginning chest compressions is not indicated, as the adolescent still has vital signs, a pulse, and spontaneous respirations. CPR would only be initiated if there was a confirmed absence of breathing and pulse.
D. Preparing to give phenytoin PO stat is not appropriate because the adolescent is NPO and at risk for aspiration. If anticonvulsants are required, the IV route would be used instead of oral administration.
E. Suctioning the oral cavity is appropriate to maintain airway patency and clear secretions that may accumulate during seizure activity or when the client is drowsy and unable to handle secretions effectively.
F. Inserting a bite block is unsafe during seizures, as it can break teeth, injure the mouth, or obstruct the airway. Nothing should be placed in the mouth once a seizure has started.
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