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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: This statement is judgmental and discouraging. It implies that the client is not making enough effort and does not acknowledge the possible challenges or barriers that the client may face.

Choice B reason: This statement is accusatory and confrontational. It puts the blame on the client and does not offer any support or guidance.

Choice C reason: This statement is empathetic and supportive. It shows that the nurse is interested in the client's situation and wants to help them identify and overcome any obstacles that may have affected their weight loss.

Choice D reason: This statement is unrealistic and dismissive. It does not address the reasons for the weight gain and does not help the client learn from their experience. It also ignores the emotional impact of the setback.

A. Irrigate the catheter with sterile water B. Clamp the drainage catheter during ambulation C. Report viscous drainage with clots to the provider D. Remove the catheter if the client feels a strong urge to urinate

Correct Answer is C

Explanation

Choice A reason: Irrigating the catheter with sterile water is an incorrect action, because the catheter should be irrigated with sterile normal saline (0.9% sodium chloride) to prevent hemolysis of the red blood cells.

Choice B reason: Clamping the drainage catheter during ambulation is an incorrect action, because the catheter should be kept patent and unclamped at all times to prevent obstruction and infection.

Choice C reason: Reporting viscous drainage with clots to the provider is a correct action, because it indicates that the irrigation is not effective and the client may need manual irrigation or surgical intervention.

Choice D reason: Removing the catheter if the client feels a strong urge to urinate is an incorrect action, because the catheter should be left in place until the provider orders its removal. The client may feel a sensation of bladder fullness or spasms due to the irrigation fluid, which can be relieved by medication or adjustment of the flow rate.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A nurse is obtaining a weekly weight for a client who has obesity and osteoarthritis and is on a weight management program. The nurse determines that the client gained 1.36 kg (3 lb) in the past week. Which of the following statements should the nurse make?

Correct Answer is C

Explanation

A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is reinforcing discharge teaching about improving gas exchange with a client who has emphysema. Which of the following information should the nurse include in the teaching?

A nurse is assisting with the care of a client who is to receive a transfusion of packed red blood cells (RBCs). Which of the following actions should the nurse take? (Select all that apply)

A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which of the following actions should the nurse take?

A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first?

A nurse is collecting data from a client who develops a fruity breath odor, dry mouth, and extreme thirst. Which of the following additional data should the nurse collect?

A nurse is preparing to care for a group of clients after receiving change-of-shift report. From which of the following clients should the nurse collect data first?

A nurse is preparing to administer timolol eye drops for a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take?

A nurse is preparing to care for a group of clients after receiving change-of-shift report. From which of the following clients should the nurse collect data first?