A nurse is collecting data from a 4-month-old infant who has meningitis. Which of the following manifestations should the nurse expect?

Constipation

Depressed anterior fontanel

Presence of the rooting reflex

High-pitched cry

Answer and Explanation

The Correct Answer is D

D. A high-pitched cry, often described as a "crying in pain" or "irritable cry," can be a characteristic sign of meningitis in infants. The cry may sound different from the infant's usual cry and may be associated with irritability, discomfort, or pain. It can be indicative of increased intracranial pressure and neurological irritation caused by the inflammation of the meninges.

A. Constipation is not typically associated with meningitis in infants. Meningitis is an inflammation of the membranes surrounding the brain and spinal cord, which can cause symptoms such as fever, irritability, poor feeding, vomiting, and lethargy.

B. A depressed anterior fontanel (sunken soft spot on the baby's head) is not a typical manifestation of meningitis. Meningitis may cause signs of increased intracranial pressure, such as a bulging fontanel, rather than a depressed fontanel.

C. he presence of the rooting reflex is not specific to meningitis. The rooting reflex is a normal reflex present in infants, where they turn their head toward a stimulus (such as stroking the cheek or corner of the mouth) in search of nourishment (typically the breast or bottle).

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Correct Answer is D

Explanation

D. The correct action would be to place the client on NPO (Nothing by Mouth) status, option D. This is because a decreased level of consciousness can increase the risk of aspiration.

A. Liver biopsy is not indicated for suspected meningitis with a decreased level of consciousness. Liver biopsy is a procedure used to obtain a sample of liver tissue for diagnostic purposes, typically to evaluate liver function or diagnose liver diseases.

B. A protective environment (option B) is more related to immunocompromised patients. In the case of decreased level of consciousness, preventing aspiration is key.

C. Dorsal recumbent position refers to lying on the back with the knees flexed. While this position may be suitable for certain medical procedures or examinations, it is not specifically indicated for a client with suspected meningitis and a decreased level of consciousness.

A. Cardiovascular B. Respiratory C. Integumentary D. Gastrointestinal

Correct Answer is A

Explanation

A. Kawasaki disease is a systemic vasculitis that predominantly affects medium-sized arteries, including the coronary arteries of the heart. The inflammation of the blood vessels can lead to coronary artery aneurysms and other cardiovascular complications if not promptly treated.

B. The respiratory system is not primarily affected by Kawasaki disease. While Kawasaki disease is a systemic illness that can cause fever and inflammation, it primarily affects the cardiovascular system, with inflammation of blood vessels, particularly the coronary arteries.

C. The integumentary system (skin, hair, nails) is not primarily affected by Kawasaki disease. Although some children with Kawasaki disease may develop a rash, particularly in the acute phase of the illness, skin involvement is not the primary feature of the disease.

D. Gastrointestinal symptoms, such as abdominal pain, vomiting, or diarrhea, can occur in Kawasaki disease but they are not the primary focus of the disease. Kawasaki disease primarily affects the cardiovascular system, leading to inflammation of blood vessels and potential complications such as coronary artery aneurysms.

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A nurse is collecting data from a 4-month-old infant who has meningitis. Which of the following manifestations should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who has suspected meningitis and a decrease level of consciousness. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a child who has Kawasaki disease. Which of the following systems is primarily affected by this disease?

Correct Answer is A

Explanation

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