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: Bacterial meningitis is a probable condition, as it is an infection of the membranes that cover the brain and spinal cord, caused by various bacteria, such as Streptococcus pneumoniae, Neisseria meningitidis, or Haemophilus influenzae. The adolescent has many signs and symptoms of bacterial meningitis, such as fever, headache, and neck stiffness.
Choice B reason: Viral meningitis is not a likely condition, as it is an infection of the membranes that cover the brain and spinal cord, caused by various viruses, such as enteroviruses, herpes simplex virus, or mumps virus. The adolescent has some signs and symptoms of viral meningitis, such as fever, headache, and neck stiffness, but they are usually less severe than bacterial meningitis.
Choice C reason: Encephalitis is not a probable condition, as it is an inflammation of the brain tissue, usually caused by viral infections, such as herpes simplex virus, West Nile virus, or rabies virus. The adolescent has some signs and symptoms of encephalitis, such as fever, headache, and altered mental status, but they are usually accompanied by focal neurological deficits, such as seizures, paralysis, or cranial nerve palsies.
Choice D reason: Brain abscess is not a definite condition, as it is a collection of pus within the brain tissue, usually caused by bacterial infections that spread from other parts of the body, such as the ear, sinus, or lung. The adolescent has some signs and symptoms of brain abscess, such as fever, headache, and altered mental status, but they are usually accompanied by focal neurological deficits, such as seizures, paralysis, or cranial nerve palsies.
Correct Answer is D
Explanation
Choice A reason: Tetany is not a typical finding in an infant who is dehydrated. Tetany is a condition where the muscles contract involuntarily and cause spasms or cramps. It is usually caused by low calcium levels or alkalosis, not dehydration.
Choice B reason: Slow, bounding pulse is not a typical finding in an infant who is dehydrated. A slow, bounding pulse may indicate increased intracranial pressure or heart failure, not dehydration. A fast, weak pulse is more likely to occur in an infant who is dehydrated.
Choice C reason: Decreased temperature is not a typical finding in an infant who is dehydrated. A decreased temperature may indicate hypothermia or sepsis, not dehydration. A normal or slightly elevated temperature is more likely to occur in an infant who is dehydrated.
Choice D reason: Irritability is a typical finding in an infant who is dehydrated. Irritability indicates that the infant is uncomfortable and thirsty. It may also be a sign of cerebral dehydration, which can affect the infant's mental status and behavior.
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