A nurse is collecting data from a client who has encephalitis due to West Nile virus. Which of the following findings should the nurse expect? (Select all that apply.)

Unilateral weakness

Stiff neck

Photophobia

Epigastric pain

Lethargy

Answer and Explanation

Correct Answer : B,C,E

Choice A reason: Unilateral weakness is an incorrect finding, because it is more indicative of a stroke or a brain tumor than encephalitis. Encephalitis is an inflammation of the brain that can cause neurological symptoms, but they are usually bilateral and symmetrical.

Choice B reason: Stiff neck is a correct finding, because it is a sign of meningeal irritation, which can occur in encephalitis due to the involvement of the meninges (the membranes that cover the brain and spinal cord).

Choice C reason: Photophobia is a correct finding, because it is another sign of meningeal irritation, which can cause sensitivity to light and sound.

Choice D reason: Epigastric pain is an incorrect finding, because it is not related to encephalitis. Epigastric pain is more likely to be caused by a gastrointestinal disorder, such as gastritis or peptic ulcer.

Choice E reason: Lethargy is a correct finding, because it is a sign of altered mental status, which can occur in encephalitis due to the damage to the brain tissue.

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Correct Answer is C

Explanation

Choice A reason: A client who has BPH and reports dysuria is not the highest priority, because dysuria is a common symptom of BPH and does not indicate an acute complication. The nurse should monitor the client's urinary output and provide comfort measures.

Choice B reason: A client who has ulcerative colitis and reports diarrhea is not the highest priority, because diarrhea is a chronic symptom of ulcerative colitis and does not indicate an acute complication. The nurse should assess the client's hydration status and electrolyte levels and administer medications as prescribed.

Choice C reason: A client who has emphysema and reports dyspnea is the highest priority, because dyspnea is a sign of respiratory distress and can indicate an acute exacerbation of emphysema. The nurse should assess the client's oxygen saturation and respiratory rate and administer oxygen therapy as prescribed.

Choice D reason: A client who has esophageal cancer and reports painful swallowing is not the highest priority, because painful swallowing is a common symptom of esophageal cancer and does not indicate an acute complication. The nurse should provide the client with soft or liquid foods and administer analgesics as prescribed.

A. Use pursed-lip breathing during periods of dyspnea. B. Limit fluid intake to 1,500 ml per day. C. Practice chest breathing each day. D. Wear home oxygen to maintain an SpO2 of at least 94%.

Correct Answer is A

Explanation

Choice A reason: This is the correct information, because pursed-lip breathing can help improve gas exchange by creating positive pressure in the airways, preventing air trapping and alveolar collapse, and increasing the exhalation time.

Choice B reason: This is an incorrect information, because limiting fluid intake to 1,500 ml per day can cause dehydration and thickening of the respiratory secretions, which can impair gas exchange and increase the risk of infection.

Choice C reason: This is an incorrect information, because practicing chest breathing each day can worsen gas exchange by increasing the use of accessory muscles, decreasing the diaphragmatic excursion, and reducing the lung expansion.

Choice D reason: This is an incorrect information, because wearing home oxygen to maintain an SpO2 of at least 94% can be harmful for a client who has emphysema, as it can suppress the hypoxic drive and cause carbon dioxide retention, which can lead to respiratory acidosis and coma. The client who has emphysema should wear home oxygen to maintain an SpO2 of 88% to 92%, or as prescribed by the provider.

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A nurse is collecting data from a client who has encephalitis due to West Nile virus. Which of the following findings should the nurse expect? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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