A nurse is caring for a client with a temperature of 39°C (102.2°F) who presents with a stiff neck and photophobia. Which condition should the nurse suspect?

Meningitis.

Encephalitis.

Migraine.

Sinusitis.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Meningitis presents with fever, stiff neck, and photophobia. It is an inflammation of the membranes surrounding the brain and spinal cord, often caused by infection.
Choice B rationale
Encephalitis involves inflammation of the brain itself, presenting with fever, headache, and altered mental status, but not specifically photophobia.
Choice C rationale
Migraine can cause photophobia and headache but is not typically associated with fever and stiff neck.
Choice D rationale
Sinusitis can cause fever and headache but not typically photophobia and stiff neck.

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Correct Answer is B

Explanation

Choice A rationale
Deep vein thrombosis (DVT) can lead to pulmonary embolism but does not directly cause chest pain and shortness of breath.
Choice B rationale
Pulmonary embolus (PE) is characterized by chest pain, shortness of breath, and hemoptysis (coughing up blood), especially in patients on bed rest.
Choice C rationale
Anemia can cause fatigue and shortness of breath but not typically chest pain and hemoptysis.
Choice D rationale
Right heart failure can cause shortness of breath and edema but not typically chest pain and hemoptysis.

A. The client has a respiratory rate of 22 breaths per minute. B. The client has a temperature of 38°C (100.4°F). C. The client has a pulse oximetry reading of 88%. D. The client has a blood pressure of 140/90 mmHg.

Correct Answer is C

Explanation

Choice A rationale
A respiratory rate of 22 breaths per minute is slightly elevated but not necessarily concerning for a client with COPD. COPD patients often have higher respiratory rates due to their chronic lung condition.
Choice B rationale
A temperature of 38°C (100.4°F) indicates a fever, which could be a sign of infection. However, it is not the most concerning finding in a COPD patient.
Choice C rationale
A pulse oximetry reading of 88% is concerning because it indicates hypoxemia. COPD patients often have lower oxygen levels, but a reading below 90% is worrisome and may require supplemental oxygen or other interventions.
Choice D rationale
A blood pressure of 140/90 mmHg is elevated but not immediately concerning in the context of COPD. It is important to monitor, but it is not the most critical finding.

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A nurse is caring for a client with a temperature of 39°C (102.2°F) who presents with a stiff neck and photophobia. Which condition should the nurse suspect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

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