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 D

Explanation

Choice A reason: This is an important action, but not the first one. The nurse should provide oxygen after lowering the client to the floor and protecting the head, to improve the oxygenation and prevent hypoxia.

Choice B reason: This is an important action, but not the first one. The nurse should turn the client onto his side after lowering the client to the floor and protecting the head, to prevent aspiration and maintain a patent airway.

Choice C reason: This is a helpful action, but not the first one. The nurse should provide privacy after lowering the client to the floor and protecting the head, to respect the client's dignity and reduce the stimulation.

Choice D reason: This is the first action, because lowering the client to the floor and protecting the head can prevent injury and trauma to the client during the seizure. The nurse should use a pillow, blanket, or towel to cushion the head, and move any furniture or objects away from the client.

A. Ambulate the client every 1 hr. B. Apply cold compresses to painful joints. C. Withhold opioids until the crisis is resolved. D. Administer oxygen via nasal cannula.

Correct Answer is D

Explanation

Choice A reason: This is an incorrect intervention, because ambulating the client every 1 hr can increase the oxygen demand and worsen the sickling of the red blood cells.

Choice B reason: This is an incorrect intervention, because applying cold compresses to painful joints can cause vasoconstriction and reduce the blood flow to the affected areas.

Choice C reason: This is an incorrect intervention, because withholding opioids until the crisis is resolved can cause unnecessary suffering and increase the stress response, which can trigger more sickling.

Choice D reason: This is the correct intervention, because administering oxygen via nasal cannula can improve the oxygen saturation and prevent further sickling of the red blood cells.

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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.)

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