A nurse is collecting data from a school-age child who has bacterial meningitis. Which of the following findings should the nurse expect? (Select all that apply.)
Headache.
Negative Kernig sign.
Vomiting.
Seizures.
Tinnitus.
Correct Answer : A,B,C,D
Choice A rationale:
Headache is an expected finding in a school-age child with bacterial meningitis. Bacterial meningitis is an inflammation of the meninges, and the membranes surrounding the brain and spinal cord, often caused by bacteria. The inflammatory process can lead to increased intracranial pressure, which commonly presents as a headache. This headache is often severe and can be accompanied by other symptoms like fever, irritability, and sensitivity to light.
Choice B rationale:
A negative Kernig sign is a possible finding in a school-age child with bacterial meningitis. Kernig sign is a clinical test performed to assess for meningitis. A positive Kernig sign is characterized by resistance and pain in extending the knee when the hip is flexed at a 90-degree angle. However, a negative Kernig sign does not rule out meningitis, as it might not always be present.
Choice C rationale:
Vomiting is an expected finding in a school-age child with bacterial meningitis. The increase in intracranial pressure due to inflammation of the meninges can lead to nausea and vomiting. The vomiting is often projectile and may not be relieved by eating or drinking.
Choice D rationale:
Seizures are an expected finding in a school-age child with bacterial meningitis. The inflammation of the brain and meninges can irritate the brain tissue and trigger seizures. Seizures in the context of bacterial meningitis might be generalized or focal in nature.
Choice E rationale:
Tinnitus (ringing in the ears) is not a typical finding associated with bacterial meningitis. The main symptoms of bacterial meningitis are related to the central nervous system and meningeal irritation, such as headache, fever, neck stiffness, and neurological changes. Tinnitus is not a common manifestation of bacterial meningitis and is not part of the typical clinical picture.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is C
Explanation
Choice A rationale:
A 2 cm scalp laceration, while a concern, is not the nurse's priority in this scenario. The child's head injury could potentially be serious, but priority should be given to neurological assessments and signs of increased intracranial pressure.
Choice B rationale:
Nasal discharge negative for glucose is not indicative of a major issue in this context. While cerebrospinal fluid (CSF) leaking from the nose after head trauma is a concern, it is not mentioned in this scenario, and this choice does not take precedence over other neurological signs.
Choice C rationale:
This is the correct answer. Asymmetric pupils can be a sign of a serious neurological issue, such as a brain injury or increased intracranial pressure. It requires immediate attention and further evaluation to assess the child's neurological status and determine the extent of the injury.
Choice D rationale:
A negative Babinski reflex is a normal finding in this context and does not require immediate priority attention. The Babinski reflex is typically present in infants and disappears as the child grows older. Its absence is expected in older children and adults.
Correct Answer is C
Explanation
Choice A rationale:
Decreased white blood cells (WBCs) in cerebrospinal fluid (CSF) would not support the diagnosis of bacterial meningitis. In bacterial meningitis, the presence of bacteria triggers an inflammatory response, leading to an increase in WBCs in the CSF (pleocytosis).
Choice B rationale:
Elevated glucose levels in CSF would actually be more consistent with viral rather than bacterial meningitis. In bacterial meningitis, glucose levels are typically decreased due to the high metabolic demands of bacteria on the glucose present in the CSF.
Choice C rationale:
Elevated total protein in cerebrospinal fluid (CSF) is indicative of inflammation and disruption of the blood-brain barrier. Bacterial meningitis causes an intense inflammatory response, leading to an increase in total protein in the CSF.
Choice D rationale:
Decreased pressure in the CSF would not be a characteristic finding in bacterial meningitis. In fact, bacterial meningitis often leads to an increase in CSF pressure due to the inflammation and accumulation of inflammatory cells and proteins.
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