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

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A reason: This is a contraindication for the MMR immunization, which is a live attenuated vaccine. A child who has a congenital immunodeficiency may not be able to mount an adequate immune response to the vaccine and may be at risk of developing the diseases from the vaccine.

Choice B reason: This is not a contraindication for the MMR immunization. A mild fever after a previous immunization is not a sign of an allergic reaction or a serious adverse effect. The child can still receive the MMR immunization as long as they do not have a moderate or severe illness.

Choice C reason: This is not a contraindication for the MMR immunization. Taking antibiotics for otitis media does not interfere with the effectiveness or safety of the vaccine. The child can still receive the MMR immunization as long as they do not have a moderate or severe illness.

Choice D reason: This is not a contraindication for the MMR immunization. A mild cough and a low-grade fever are not signs of a moderate or severe illness that would prevent the child from receiving the vaccine. The child can still receive the MMR immunization as long as they do not have any other contraindications.

A. A sibling who had a sore throat 3 weeks ago B. A neighbor's child who has chickenpox C. A classmate who has fifth disease D. The father who had gastritis 2 weeks ago

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.

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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?

Nursing Test Bank

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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