A nurse in the emergency department is evaluating a young adult client for bacterial meningitis. Which of the following actions should the nurse take as part of the focused assessment?

Tap the client's facial nerve and note any facial twitching.

Strike the client's patellar tendon with a percussion hammer and note any increase in response.

Gently elevate the client's head and note any nuchal rigidity.

Run a tongue blade on the outside of the client's sole and note any flaring of the toes.

Answer and Explanation

The Correct Answer is C

Choice A reason: Tapping the client's facial nerve and noting any facial twitching is not a specific assessment for bacterial meningitis. This action is more related to evaluating facial nerve function and is not typically used to diagnose meningitis.

Choice B reason: Striking the client's patellar tendon with a percussion hammer and noting any increase in response is a test for reflexes, which may or may not be altered in bacterial meningitis. An increased response can be seen in various neurological conditions and is not specific to meningitis.

Choice C reason: Gently elevating the client's head and noting any nuchal rigidity is a key part of the focused assessment for bacterial meningitis. Nuchal rigidity, or stiffness of the neck, is a classic sign of meningitis and is assessed by gently lifting the head and attempting to move the chin toward the chest. If the client resists due to pain or stiffness, this could indicate nuchal rigidity associated with meningitis.

Choice D reason: Running a tongue blade on the outside of the client's sole and noting any flaring of the toes, known as the Babinski sign, is used to assess for central nervous system lesions and is not specific to meningitis. While it can be part of a neurological assessment, it does not specifically indicate bacterial meningitis.

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Correct Answer is B

Explanation

Choice A reason: Administering prescribed corticosteroids is not the appropriate action for dyspnea associated with fluid overload from IV infusion. Corticosteroids are typically used to manage inflammatory conditions and are not indicated for this scenario.

Choice B reason: Slowing the infusion rate is the correct action when signs of fluid overload are present, such as dyspnea and hypertension. This helps to prevent further fluid accumulation. Contacting the provider is essential for further evaluation and management, which may include adjusting the fluid regimen or prescribing diuretics to manage the fluid overload.

Choice C reason: Lowering the head of the bed to a semi-Fowler's position may provide temporary relief for dyspnea but does not address the underlying issue of fluid overload. It is a supportive measure but should be accompanied by other interventions to manage the client's condition.

Choice D reason: Changing the infusion to lactated Ringer's would not address the issue of fluid overload and could potentially exacerbate the situation if the rate is maintained. The type of IV fluid is less important than the volume and rate of administration in the case of fluid overload.

A. Anticonvulsant B. Diuretic C. Antithrombotic D. Opioid analgesic

Correct Answer is C

Explanation

Choice A reason: Anticonvulsants are medications used to prevent seizures. While seizures can occur after a stroke, anticonvulsants are not routinely prescribed unless the patient has a history of seizures or has experienced seizures post-stroke. Therefore, anticonvulsants would not be the standard pharmacologic therapy for all patients being discharged after an ischemic stroke.

Choice B reason: Diuretics are used to remove excess fluid from the body and are commonly prescribed for conditions such as heart failure or high blood pressure. They are not typically used as a standard treatment for ischemic stroke unless the patient has a specific condition that requires fluid management.

Choice C reason: Antithrombotic agents, such as aspirin or clopidogrel, are commonly prescribed to patients after an ischemic stroke to prevent further clot formation and reduce the risk of recurrent strokes. These medications work by inhibiting platelet aggregation and are a key part of secondary prevention in stroke management.

Choice D reason: Opioid analgesics are strong painkillers that are used to treat severe pain. They are not typically prescribed upon discharge for ischemic stroke patients unless there is a specific indication for pain management that cannot be managed with other medications.

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A nurse in the emergency department is evaluating a young adult client for bacterial meningitis. Which of the following actions should the nurse take as part of the focused assessment?

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Correct Answer is B

Explanation

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