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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 D

Explanation

A. Therapeutic effects of medications may not be seen for 2-3 weeks: While it is important for the client to understand the timeline for therapeutic effects, ensuring medication adherence, especially during the initial period when therapeutic effects are not yet apparent, is of higher priority.
B. Physical dependency may result from extended use of medications: While the potential for physical dependency is an important consideration, ensuring medication compliance and adherence to the prescribed regimen, particularly in the context of managing seizures, takes precedence.
C. Urine may turn pink to brown but is not harmful: While this information may be included in the education plan to address potential side effects of antiepileptic medications, it is not the highest priority compared to ensuring the client understands the importance of taking medication regularly.
D. Take medication even if there is no seizure activity: Ensuring consistent medication adherence is crucial in managing seizure disorders to maintain therapeutic blood levels of antiepileptic medications and reduce the risk of breakthrough seizures. Missing doses can increase the risk of seizure recurrence.

A. Suction Tubing B. Nasogastric Tube C. Urinary Catheter D. Tongue Blade E. Oxygen Mask F. Side Rail Pad

Correct Answer is ["A","E","F"]

Explanation

A. Suction Tubing: This equipment is necessary for clearing the patient's airway in case of any secretions or vomitus that could obstruct breathing following a seizure episode.

B. Nasogastric Tube: While nasogastric tubes may be necessary in some medical conditions, they are not typically indicated following treatment for status epilepticus unless there are specific concerns related to the patient's condition that require gastric decompression or feeding.

C. Urinary Catheter: While urinary catheters may be used in some cases, they are not routinely required following treatment for status epilepticus unless there are specific concerns about urinary retention or monitoring of urine output.

D. Tongue Blade: Tongue blades are not typically necessary following treatment for status epilepticus. They may pose a risk of injury to the patient if used unnecessarily.

E. Oxygen Mask: Oxygen masks are essential for providing supplemental oxygen to the patient, especially if there are concerns about hypoxia following a seizure episode.

F. Side Rail Pad: Side rail pads are important for preventing injury to the patient during postictal confusion or agitation. They help to protect the patient from accidentally falling out of bed or injuring themselves against the bed rails.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following should be the highest priority of education plan for a client being treated with medication therapy for a generalized seizure disorder?

Correct Answer is D

Explanation

A patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient's assigned room? (Select all that apply.)

Correct Answer is ["A","E","F"]

Explanation

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

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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?

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