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 A

Explanation

Choice A rationale
Administering antihypertensive medication as prescribed is the priority action for a client with a history of hypertension presenting with severe headache, blurred vision, and confusion.
These symptoms suggest a hypertensive crisis, which requires immediate blood pressure reduction to prevent further complications.
Choice B rationale
Preparing the client for a lumbar puncture is not the priority action in this scenario. While a lumbar puncture may be necessary to rule out other conditions, the immediate concern is to manage the hypertensive crisis.
Choice C rationale
Initiating seizure precautions is important if the client is at risk of seizures, but the priority action is to address the hypertensive crisis by administering antihypertensive medication.
Choice D rationale
Monitoring the client’s blood glucose levels is important for overall health management, but it is not the priority action in this scenario. The immediate concern is to manage the hypertensive crisis.

A. Post-renal acute kidney injury (AKI). B. Diabetes insipidus (DI). C. Syndrome of inappropriate antidiuretic hormone (SIADH). D. Congestive heart failure (CHF).

Correct Answer is D

Explanation

Choice A rationale
Post-renal acute kidney injury (AKI) is caused by obstruction of urine flow, leading to decreased urine output, but it does not typically cause crackles in the lungs.
Choice B rationale
Diabetes insipidus (DI) is characterized by excessive urination and thirst due to a deficiency of antidiuretic hormone (ADH), but it does not cause crackles in the lungs.
Choice C rationale
Syndrome of inappropriate antidiuretic hormone (SIADH) involves excessive release of ADH, leading to water retention and hyponatremia, but it does not cause crackles in the lungs.
Choice D rationale
Congestive heart failure (CHF) can lead to fluid accumulation in the lungs (crackles) and decreased urine output due to poor cardiac function and renal perfusion.

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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

A nurse is assessing a client with a history of hypertension who presents with a severe headache, blurred vision, and confusion. The nurse should prioritize which of the following actions?

Correct Answer is A

Explanation

A nurse is caring for a client with chronic kidney disease (CKD) who has elevated intracranial pressure (ICP). While assessing the client, the nurse hears crackles in the lungs and notes a decrease in urine output.Which complication has the client likely developed?

Correct Answer is D

Explanation

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