A nurse is assessing a client who was brought into the emergency room following a seizure. The nurse suspects the client may have meningococcal meningitis when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate next?

Administer an antipyretic.

Complete a vascular assessment.

Assess the cranial nerves.

Decrease environmental stimuli.

Answer and Explanation

The Correct Answer is C

Choice A reason:

Administering an antipyretic can help reduce fever, which is a common symptom of meningococcal meningitis. However, this action does not address the immediate need to assess the extent of neurological impairment. While fever management is important, it is not the first priority in this situation.

Choice B reason:

Completing a vascular assessment is important to evaluate the client’s circulatory status, especially if there are signs of septicemia. However, in the context of suspected meningococcal meningitis, the priority is to assess the neurological status to determine the extent of central nervous system involvement. This will guide further treatment and interventions.

Choice C reason:

Assessing the cranial nerves is crucial in a client with suspected meningococcal meningitis. This assessment helps determine the extent of neurological impairment and can provide critical information about the progression of the disease. Early identification of neurological deficits can guide immediate and appropriate interventions to prevent further complications.

Choice D reason:

Decreasing environmental stimuli can help reduce discomfort for the client, especially if they are experiencing photophobia or other sensory sensitivities. However, this action does not address the immediate need to assess the client’s neurological status. It is a supportive measure that can be implemented after more critical assessments are completed.

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Correct Answer is B

Explanation

Choice A reason:

The use of antibiotics to fight infections significantly improved health outcomes and reduced mortality rates from bacterial infections. However, antibiotics were not widely available until the mid-20th century. The dramatic increase in life expectancy began earlier, largely due to improvements in public health measures.

Choice B reason:

Sanitation and other public health activities were most responsible for the dramatic increase in life expectancy during the twentieth century. Improvements in sanitation, such as clean water supply, sewage treatment, and waste disposal, drastically reduced the incidence of infectious diseases. Public health initiatives, including vaccination programs and health education, also played a crucial role in preventing disease and promoting health.

Choice C reason:

Technology increases in the field of medical laboratory research have contributed to advancements in medical knowledge and treatment. While these technological advancements have improved diagnostic capabilities and treatment options, they were not the primary drivers of the initial increase in life expectancy during the early 20th century.

Choice D reason:

Advances in surgical techniques and procedures have significantly improved outcomes for many medical conditions. However, these advances primarily benefited individuals who had access to surgical care and did not have as widespread an impact on overall life expectancy as public health measures did.

A. Administer thrombolytics B. Call for help C. Provide the client with water to test the gag reflex. D. Perform carotid massage.

Correct Answer is B

Explanation

Choice A reason:

Administering thrombolytics is not the first action the nurse should take. Thrombolytics are used to treat ischemic strokes, but their administration requires a thorough assessment and confirmation of the diagnosis through imaging studies. Immediate action is needed to ensure the client’s safety and initiate the stroke protocol.

Choice B reason:

Calling for help is the first action the nurse should take. The client is exhibiting signs of a possible stroke, and immediate medical intervention is required. Calling for help ensures that the stroke team or emergency response team is activated promptly to provide the necessary care.

Choice C reason:

Providing the client with water to test the gag reflex is not appropriate in this situation. The client may have difficulty swallowing, and giving water could lead to aspiration. The priority is to ensure the client’s safety and initiate the stroke protocol.

Choice D reason:

Performing carotid massage is not indicated for a client with new right-sided weakness and slurred speech. Carotid massage is used to manage certain types of arrhythmias, but it is not appropriate for suspected stroke. The focus should be on immediate assessment and intervention.

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Naxlex Comprehensive Predictor Exams

A nursing preceptor is reviewing life expectancy in the twentieth century with a new nurse. The nurse should recognize that which of the following was most responsible for the dramatic increase in life expectancy during the twentieth century?

Correct Answer is B

Explanation

A nurse enters the room of a client and discovers the client with new right-sided weakness and slurred speech. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

The nurse is caring for a client with multiple sclerosis. What action does the nurse implement to increase venous return, prevent stiffness, and maintain muscle strength and endurance?

A nurse is providing education regarding biologic threats. When discussing anthrax, which of the following should be included as potential portals of entry? SELECT ALL THAT APPLY

The school nurse identifies 12 students with confirmed cases of influenza A. The families of the children are advised to keep the children home for a minimum of 5 to 7 days. Which of the following is an appropriate action by the nurse?

A nurse is caring for a client who has Parkinson’s disease and is starting to display bradykinesia. Which of the following is an appropriate action by the nurse?

A nurse is delegating tasks to assistive personnel. Which of the following should the nurse consider when using one of the five rights of delegation?

The nurse is working on discharge planning for a 25-year-old hospitalized client diagnosed with Multiple Sclerosis (MS). The client has significant bilateral lower extremities muscle weakness. Which of the following facilities should the nurse expect this client to be discharged to?

A nurse is caring for a client brought to the Emergency Department as one of the first victims of a train accident. The nurse assesses the client, noting a respiratory rate of 38, a weak, rapid pulse, and uncontrolled bleeding. Using NATO guidelines, the nurse assigns which priority tag?

A nurse is caring for a client scheduled for a functional assessment who asks, “What is the purpose of this assessment?” How should the nurse most appropriately respond to the client?