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A nurse is caring for a client who has just been admitted to the emergency department (ED).

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Potential Condition

Meningitis: The client's symptoms of severe headache, fever, photophobia, nuchal rigidity, and lethargy are characteristic of meningitis. The presence of these signs suggests inflammation of the protective membranes surrounding the brain and spinal cord. Immediate evaluation and treatment are essential due to the potential severity of this condition.
Septic shock: While the client presents with fever and tachycardia, the vital signs and symptoms do not strongly indicate septic shock, which typically involves more profound hypotension, altered mental status, and signs of organ dysfunction. The client’s blood pressure remains relatively stable despite other symptoms.
Migraine headache: Although the client reports a severe headache, the additional symptoms of fever, photophobia, and nuchal rigidity suggest an infectious process rather than a primary headache disorder. Migraines do not usually present with systemic signs such as fever and muscle rigidity.
Hydrocephalus: Hydrocephalus typically presents with increased intracranial pressure, characterized by symptoms such as headache, nausea, vomiting, and altered mental status. The client’s primary complaint is a headache and neck stiffness, but there are no indications of increased intracranial pressure or the classic triad of symptoms seen in hydrocephalus.

Actions to Take:

Initiate neurological checks every 2 hr: Frequent neurological assessments are crucial for monitoring changes in mental status, level of consciousness, and other signs of increased intracranial pressure or neurological deterioration. This helps ensure timely interventions if the client's condition worsens.
Decrease environmental stimuli: Reducing noise and light in the environment can help minimize discomfort and agitation for the client with meningitis, particularly given their symptoms of photophobia and malaise. A calm and quiet environment promotes comfort and supports recovery.
Prepare the client for surgery: While surgery may be necessary in some cases of meningitis, it is not an immediate action to take without further evaluation or evidence of complications such as an abscess. The primary focus should be on monitoring and supportive care initially.
Administer gabapentin: Gabapentin is typically used for neuropathic pain or seizures, not as a primary treatment for meningitis. The immediate treatment for meningitis involves antibiotics and supportive care rather than gabapentin.

Parameters to Monitor:

Temperature: Monitoring temperature is vital in clients with meningitis to assess for ongoing infection and evaluate the effectiveness of antipyretic interventions. Fever management is important in reducing metabolic demand and preventing further complications.
Lactate level: Elevated lactate levels can indicate tissue hypoperfusion and may signify the severity of infection or sepsis. Monitoring lactate helps assess the client's overall condition and response to treatment, guiding further interventions as needed.
Bowel sounds: Monitoring bowel sounds is not a priority in the context of meningitis and does not provide relevant information about the client's neurological status or condition.
Vascular changes: While assessing vascular changes can be important in some critical conditions, it is not directly related to the management of meningitis. The focus should be on neurological and systemic assessments.
Gait: Gait assessment may be relevant for neurological conditions but is not applicable in this acute setting where the client is presenting with signs of meningitis. The priority is to monitor neurological status and vital signs rather than gait at this time.

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Correct Answer is C

Explanation

A. 150 mL of greenish yellow NG drainage: This amount and color of drainage are expected after abdominal surgery, as bile-stained gastric contents can be present. It does not indicate a complication that requires provider notification.

B. Client requests medication for nausea: Nausea is a common postoperative symptom, often managed with antiemetics. While it should be addressed, it is not an urgent finding that requires immediate provider notification.

C. Urinary output of 250 mL over past 12 hr: Oliguria, defined as urine output less than 30 mL/hr (or less than 400 mL in 24 hr), suggests inadequate renal perfusion, possibly due to hypovolemia or acute kidney injury. This finding requires prompt provider notification.

D. Hypoactive bowel sounds: Reduced bowel activity is common after abdominal surgery due to anesthesia and opioid use. While monitoring is necessary, hypoactive sounds alone are not an urgent concern unless accompanied by other signs of ileus or obstruction.

A. Apply dressing to foot wound. B. Consult outpatient wound care specialist. C. Schedule appointment with ophthalmologist. D. Administer regular insulin 4 units subcutaneously x 1 dose

Correct Answer is D

Explanation

Apply dressing to foot wound: While wound care is important, managing hyperglycemia takes priority. High blood glucose impairs wound healing and increases infection risk, making insulin administration the more urgent intervention. Dressing application should follow glycemic control measures.

Consult outpatient wound care specialist: A wound care consultation is appropriate for managing a chronic ulcer, but immediate intervention is required to stabilize glucose levels. Optimizing wound care should come after initial glucose management.

Schedule appointment with ophthalmologist: Clients with diabetes require routine eye exams due to the risk of diabetic retinopathy. However, addressing hyperglycemia and preventing further infection are more urgent concerns at this time.

Administer regular insulin 4 units subcutaneously x 1 dose: The client's blood glucose is elevated (250 mg/dL), which can impair immune function and tissue healing. Lowering glucose with insulin is the priority to prevent complications such as worsening infection or ketoacidosis.

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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