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A nurse in the emergency department is caring for a client.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

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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Correct Answer is ["B","D"]

Explanation

A. Slurred speech: This can be a sign of increased ICP but is not typically considered a late sign. It is more often associated with early or moderate increases in ICP when the brain is starting to experience pressure but is not yet at a critical stage.
B. Bradycardia: This is a late sign of increased ICP and is part of Cushing's triad, which includes bradycardia, irregular respirations, and a widened pulse pressure. Bradycardia occurs as a compensatory mechanism to decrease the cerebral blood flow in response to increased ICP.
C. Hypotension: While changes in blood pressure can be associated with ICP, hypotension is not typically a late sign of increased ICP. In fact, hypertension with a widened pulse pressure would be more indicative of increased ICP as part of Cushing's triad.
D. Nonreactive dilated pupils: This is a late sign of increased ICP and indicates brain stem herniation or compression, which is a medical emergency. The pupils become fixed and dilated as the oculomotor nerve is compressed due to increased pressure.
E. Confusion: Confusion can be an early sign of increased ICP as it indicates changes in mental status. However, it is not specifically a late sign of increased ICP, as it can occur at various stages of pressure changes within the brain.

A. Furnish restraints at the bedside. B. Keep an oxygen setup at the bedside. C. Place the bed in the lowest position. D. Provide a suction setup at the bedside. E. Elevate the side rails near the head when the client is in bed.

Correct Answer is ["B","D"]

Explanation

A. Furnish restraints at the bedside: Restraints are not indicated for clients with seizure disorders. In fact, restraints can increase the risk of injury during a seizure and should be avoided.

B. Keep an oxygen setup at the bedside: Oxygen may be necessary to support the client's respiratory function during and after a seizure. Having an oxygen setup readily available can ensure prompt administration if needed.

C. Place the bed in the lowest position: Lowering the bed can help prevent injury if the client
falls out of bed during a seizure. However, it is not always feasible or necessary to lower the bed to the lowest position, especially if the client has mobility limitations or other considerations.

D. Provide a suction setup at the bedside: Suctioning may be necessary to clear the airway and prevent aspiration if the client experiences excessive oral secretions or vomiting during or after a seizure.

E. Elevate the side rails near the head when the client is in bed: Elevating the side rails near the head can help prevent injury if the client thrashes or moves unpredictably during a seizure. However, it is essential to ensure that the client's head and neck remain adequately supported and that the side rails do not restrict access to the client during a seizure.

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Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.)

Correct Answer is ["B","D"]

Explanation

A nurse is creating a plan of care for a client who has a history of tonic-clonic seizure disorder. Which of the following interventions should the nurse include? (Select all that apply.)

Correct Answer is ["B","D"]

Explanation

The nurse identifies a patient with type 1 diabetes and a history of herpes simplex infection as being at risk for Bell's palsy. Which information should the nurse include in teaching the patient?

A patient has been taking phenytoin (Dilantin) for 2 years. Which action should the nurse take when evaluating possible adverse effects of the medication?

When assessing the client with meningitis, the nurse looks for which manifestation as a frequent first sign of increased intracranial pressure?

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

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?

A nurse is performing a neurological assessment for a client who has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III?

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?

Which information about the patient who had a subarachnoid hemorrhage is most important to communicate to the health care provider?