. A nurse is caring for a child who has been diagnosed with bacterial meningitis. Which of the following should the nurse monitor in the child? (Select All that Apply.)

Manifestations that could indicate a sepsis infection

Long-term effects that result from a prolonged recovery

Blood pressure that could indicate hypertension

Heart problems that result from cardiac dysfunction

A decrease in body temperature as a sign of bacterial meningitis progression

Answer and Explanation

Correct Answer : A,B,C

A. Manifestations that could indicate a sepsis infection should be monitored closely as bacterial meningitis can lead to septicemia. Signs such as low blood pressure, rapid heart rate, and poor perfusion need immediate attention.

B. Long-term effects that result from a prolonged recovery should be considered. Children recovering from bacterial meningitis may develop complications such as hearing loss, cognitive delays, or motor impairments, requiring long-term follow-up.

C. Blood pressure that could indicate hypertension should be monitored, as increased intracranial pressure (ICP) from meningitis may lead to systemic hypertension, an important parameter to manage during acute illness.

D. Heart problems that result from cardiac dysfunction are not commonly associated with bacterial meningitis itself. However, indirect complications such as septic shock could affect cardiac function, although this is less direct.

E. A decrease in body temperature as a sign of bacterial meningitis progression is incorrect. Hypothermia is not typically a sign of meningitis progression. Fever is a more common manifestation of bacterial meningitis and should be monitored instead.

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Correct Answer is D

Explanation

A. Have blood work done is not the initial priority for assessing cognitive status in a child with a suspected head injury. Blood work may be ordered later to assess for any contributing factors but is not the first step in cognitive assessment.

B. Monitor intracranial pressure is important but typically comes after an initial cognitive assessment. Elevated intracranial pressure may be suspected after assessing cognitive function and other neurological signs.

C. Recommend a CT scan might be ordered by a healthcare provider to assess for structural brain damage, but the initial assessment of cognitive status should be done first to evaluate the severity of the injury.

D. Use the Glasgow cognitive scale is the correct initial action. The Glasgow Coma Scale (GCS) is used to assess a child's level of consciousness and cognitive function following a head injury. It helps determine the severity of the injury and guides further intervention.

A. Brisk pupillary reaction to light. B. Increased sleepiness C. Tachycardia D. Depressed fontanels

Correct Answer is B

Explanation

A. Brisk pupillary reaction to light is a normal finding and does not indicate increased intracranial pressure (ICP). In fact, a sluggish or non-reactive pupil response is more indicative of increased ICP.

B. Increased sleepiness or lethargy is an early sign of increased ICP in infants. The brain’s response to rising pressure can cause altered mental status, which includes drowsiness or difficulty waking.

C. Tachycardia is not typically an early sign of increased ICP. As pressure increases, the heart rate can actually slow, and bradycardia (slower heart rate) is often seen in more advanced stages.

D. Depressed fontanels are not indicative of increased ICP. In fact, in infants, increased ICP is more commonly associated with bulging fontanels, not depressed ones. Depressed fontanels could indicate dehydration or malnutrition.

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. A nurse is caring for a child who has been diagnosed with bacterial meningitis. Which of the following should the nurse monitor in the child? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a child who has a suspected head injury. What would be the initial action the nurse should take to assess the child's cognitive status?

Correct Answer is D

Explanation

A nurse is assessing an infant following a motor vehicle crash. Which of the following findings should the nurse monitor to identify increased intracranial pressure?

Correct Answer is B

Explanation

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