A nurse is caring for an adolescent who was brought to the emergency department (ED) with a fever, headache, and neck stiffness. The nurse should determine the assessment findings are consistent with which of the following disease processes?
Bacterial meningitis
Encephalitis
Gastroenteritis
Migraine
The Correct Answer is A
Choice A reason: Bacterial meningitis is an inflammation of the meninges, the membranes that cover the brain and spinal cord, caused by a bacterial infection. It can cause fever, headache, neck stiffness, photophobia, and altered mental status. The cerebrospinal fluid (CSF) analysis may show increased white blood cells, protein, and glucose. The nurse should assess the neck range of motion and the reaction to pupil assessment, as these may indicate increased intracranial pressure.
Choice B reason: Encephalitis is an inflammation of the brain tissue, usually caused by a viral infection. It can cause fever, headache, confusion, seizures, and focal neurological deficits. The CSF analysis may show increased white blood cells and protein, but normal glucose. The nurse should assess the level of consciousness and the neurological status, as these may indicate brain damage.
Choice C reason: Gastroenteritis is an inflammation of the stomach and intestines, usually caused by a viral or bacterial infection. It can cause nausea, vomiting, diarrhea, abdominal pain, and dehydration. The nurse should assess the gastrointestinal manifestations and the vital signs, as these may indicate fluid and electrolyte imbalance.
Choice D reason: Migraine is a type of headache that involves recurrent episodes of moderate to severe pain, usually on one side of the head, often accompanied by nausea, vomiting, and sensitivity to light and sound. The nurse should assess the location and duration of pain, the triggers and relievers, and the history of migraine. The CSF analysis is usually normal.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the most likely source of the child's infection. Rheumatic fever is a complication of an untreated or poorly treated streptococcal infection, such as strep throat or scarlet fever. It usually occurs 2 to 4 weeks after the initial infection and causes inflammation of the heart, joints, skin, and nervous system. The nurse should ask the parent if the sibling was tested and treated for strep throat, and if the child was exposed to the sibling.
Choice B reason: This is not a likely source of the child's infection. Chickenpox is caused by the varicella-zoster virus, not by streptococci. It is a highly contagious disease that causes a blister-like rash, itching, fever, and fatigue. It does not cause rheumatic fever, but it can lead to other complications, such as bacterial skin infections, pneumonia, or encephalitis.
Choice C reason: This is not a likely source of the child's infection. Fifth disease is caused by the parvovirus B19, not by streptococci. It is a mild illness that causes a distinctive red rash on the face, body, and limbs, as well as fever, headache, and sore throat. It does not cause rheumatic fever, but it can affect the production of red blood cells and cause anemia in some people.
Choice D reason: This is not a likely source of the child's infection. Gastritis is the inflammation of the stomach lining, which can be caused by various factors, such as bacteria, viruses, medications, alcohol, or stress. It is not caused by streptococci, nor does it cause rheumatic fever. It can cause symptoms such as abdominal pain, nausea, vomiting, and loss of appetite.
Correct Answer is ["A","B","D"]
Explanation
Choice A: The reason why the child is taking the medication
It is essential for the nurse to explain why the child is taking the medication. This helps the parents or caregivers understand the importance of the medication and ensures they are more likely to adhere to the prescribed treatment plan. Knowing the reason for the medication can also help in recognizing the signs of improvement or any potential issues that may arise during the course of treatment.
Choice B: The adverse effects of the medication
Informing the parents or caregivers about the potential adverse effects of the medication is crucial. This knowledge allows them to monitor the child for any side effects and seek medical attention if necessary. It also helps in managing expectations and reduces anxiety if any common side effects occur.
Choice C: Stopping the medication when the child feels better
This is not a correct choice. It is important to complete the full course of antibiotics as prescribed, even if the child starts feeling better. Stopping the medication prematurely can lead to incomplete treatment of the infection and may contribute to antibiotic resistance.
Choice D: Written information about the medication
Providing written information about the medication is important as it serves as a reference for the parents or caregivers. This information can include dosage instructions, potential side effects, and any other relevant details. Written instructions help ensure that the medication is administered correctly and consistently.
Choice E: Using a kitchen spoon to administer the medication
This is not a correct choice. Using a kitchen spoon to administer medication is not recommended as it can lead to inaccurate dosing. It is important to use a proper measuring device, such as an oral syringe or a medication cup, to ensure the correct dosage is given.
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