A nurse is assessing a 6-month-old infant who has viral meningitis. Which of the following findings should the nurse expect? (Select all that apply)
Hyperglycemia.
Fever.
Poor feeding.
Difficult to awaken.
Stiff neck.
Correct Answer : B,C,D,E
Choice A reason: Hyperglycemia is not typically associated with viral meningitis. It may occur in metabolic disorders or stress responses but is not a hallmark of meningitis, which primarily affects the central nervous system, causing inflammation, fever, and neurological symptoms rather than blood glucose alterations.
Choice B reason: Fever is a common sign of viral meningitis due to the body’s immune response to viral infection in the meninges. Inflammation triggers pyrogens, elevating body temperature. This systemic response is a key diagnostic indicator in infants, reflecting central nervous system irritation.
Choice C reason: Poor feeding occurs in viral meningitis as infants experience lethargy and irritability from meningeal inflammation. Neurological irritation disrupts normal feeding behaviors, and systemic illness reduces appetite, leading to inadequate intake, a common symptom in infants with central nervous system infections.
Choice D reason: Difficulty awakening is expected in viral meningitis due to meningeal inflammation causing lethargy and altered consciousness. The infection irritates brain structures, reducing arousal responses, making infants less responsive, a critical sign of neurological involvement requiring prompt medical attention.
Choice E reason: Stiff neck, or nuchal rigidity, results from meningeal inflammation in viral meningitis, causing pain and resistance during neck flexion. This occurs as inflamed meninges irritate surrounding nerves, a classic symptom in older children and infants, indicating central nervous system infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Explaining the insulin injection in simple terms reduces fear and anxiety, promoting psychological comfort in pediatric diabetes care. Atraumatic care emphasizes emotional preparation, helping the child understand the procedure, which minimizes stress and enhances coping, improving long-term treatment adherence.
Choice B reason: Using a larger needle increases pain and tissue trauma, contradicting atraumatic care principles. Smaller, finer needles are standard for insulin injections to minimize discomfort, as larger needles cause more tissue disruption, increasing anxiety and pain in pediatric patients.
Choice C reason: Asking the child to look away may reduce visual anxiety but does not address emotional preparation. Atraumatic care prioritizes active engagement and understanding, like explaining the procedure, to empower the child, rather than passive distraction, which has limited long-term benefit.
Choice D reason: Administering the injection quickly reduces duration but not overall trauma. Atraumatic care involves psychological preparation and gentle technique, not just speed. Rushing risks improper administration or increased fear, whereas explaining the process fosters trust and reduces anxiety in children.
Correct Answer is D
Explanation
Choice A reason: Contact precautions are used for infections like MRSA, spread by direct touch. Measles is transmitted via airborne droplet nuclei, not skin contact. Contact precautions would not prevent the spread of measles, as they do not address the respiratory transmission route of the virus.
Choice B reason: Droplet precautions are for infections like influenza, spread by larger respiratory droplets. Measles spreads via smaller airborne particles that remain suspended, requiring stricter airborne precautions. Droplet measures are insufficient to prevent transmission in shared air spaces over longer distances.
Choice C reason: A protective environment is used for immunocompromised patients, like those undergoing transplants, to prevent infection. Measles requires precautions to protect others from the patient, not vice versa, making this inappropriate. It does not address the airborne transmission of the measles virus.
Choice D reason: Measles, caused by the rubeola virus, spreads via airborne droplet nuclei, which can remain suspended for hours. Airborne precautions, including negative-pressure rooms and N95 masks, prevent transmission by containing infectious particles, protecting healthcare workers and other patients from this highly contagious virus.
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