A nurse is assessing a patient admitted with fever, severe headache, and photophobia. Which assessment finding would most strongly support a diagnosis of bacterial meningitis?
Nuchal rigidity
Abdominal distention
Bilateral wheezing
Sternal tenderness
The Correct Answer is A
A. Nuchal rigidity: Stiff neck (nuchal rigidity) is a hallmark clinical sign of meningitis, resulting from meningeal inflammation. When present alongside fever, severe headache, and photophobia, it strongly supports a diagnosis of bacterial meningitis. This finding is part of the classic triad and is a key indicator warranting urgent diagnostic evaluation and treatment.
B. Abdominal distention: Abdominal distention is unrelated to meningitis and typically reflects gastrointestinal or intra-abdominal pathology. It does not provide evidence for meningeal infection or inflammation and is not useful in supporting the diagnosis.
C. Bilateral wheezing: Wheezing indicates lower airway obstruction, such as in asthma, bronchitis, or other pulmonary conditions. It is not associated with meningitis and does not contribute to diagnosing central nervous system infections.
D. Sternal tenderness: Sternal tenderness may suggest trauma, infection (osteomyelitis), or hematologic conditions but is not a feature of meningitis. Its presence does not support a diagnosis of bacterial meningitis in the context of fever, headache, and photophobia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["8"]
Explanation
Calculation:
- Identify the ordered dose and available concentration
Ordered Dose: 5 mg/kg
Patient Weight: 80 kg
Dose in mg = 5 × 80
= 400 mg
Available Concentration: 150 mg/3 mL = 50 mg/mL
- Calculate the volume to administer
Volume to administer = Ordered Dose ÷ Concentration
= 400 ÷ 50
= 8 mL
Correct Answer is D
Explanation
A. Decrease in cardiac output: A Swan-Ganz (pulmonary artery) catheter rarely causes an immediate decrease in cardiac output unless complications like arrhythmias or pulmonary artery rupture occur. Monitoring hemodynamics helps detect changes, but this is not the most common risk during insertion or removal.
B. Damage to the mitral valve: The catheter passes through the right atrium and right ventricle into the pulmonary artery, so the mitral valve is not in the pathway. Injury to the mitral valve is unlikely, making this a low-risk complication.
C. Myocardial infarction: Myocardial infarction is not a typical complication of Swan-Ganz catheterization unless coronary perfusion is severely compromised by another underlying condition. It is not directly caused by the catheter itself.
D. Ventricular dysrhythmias: As the catheter passes through the right ventricle, it can mechanically irritate the ventricular myocardium, leading to premature ventricular contractions, ventricular tachycardia, or other dysrhythmias. This is the most common and expected complication during insertion and removal, requiring continuous ECG monitoring.
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