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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Hematocrit 36%. A hematocrit level of 36% falls within the normal range for adolescents. Hematocrit measures the proportion of blood volume occupied by red blood cells and is used to assess for anemia or polycythemia. A level of 36% is not a cause for concern in this case.
Choice B rationale:
Hemoglobin 12 g/dL. A hemoglobin level of 12 g/dL is within the normal range for adolescents. Hemoglobin is a protein in red blood cells that carries oxygen. This level indicates that the adolescent is not significantly anemic.
Choice C rationale:
Glucose 120 mg/dL. A glucose level of 120 mg/dL is within the normal range for a random blood glucose test. However, in the context of diabetes mellitus, the nurse should be more concerned about the HbA1c level, which reflects the average blood glucose level over the past few months.
Choice D rationale:
HbA1c 10.7%. HbA1c, or glycated hemoglobin, reflects the average blood glucose concentration over a span of approximately 2 to 3 months. An HbA1c level of 10.7% is significantly elevated and indicates poor long-term glucose control. This value suggests that the adolescent's diabetes management has not been effective, which can lead to an increased risk of diabetes-related complications over time. The nurse should notify the healthcare provider so that appropriate adjustments can be made to the treatment plan.
Correct Answer is D
Explanation
Choice A rationale:
Acute otitis media is not a risk factor for physical maltreatment. It's an ear infection and does not directly contribute to the risk of physical abuse. The child's medical history should be assessed for factors that are more closely related to abuse.
Choice B rationale:
Myopia, or nearsightedness, is also not a risk factor for physical maltreatment. Myopia is a visual impairment and is not related to the risk of abuse. The nurse should focus on identifying factors that might indicate an increased likelihood of abuse.
Choice C rationale:
Prematurity can be a risk factor for various health issues in a child, but it is not directly linked to physical maltreatment. While preterm infants might have unique medical needs, being born prematurely does not inherently increase the risk of physical abuse.
Choice D rationale:
Correct Answer. Being adopted can be considered a potential risk factor for physical maltreatment. Children who are adopted might face certain challenges related to attachment, identity, and adjustment. It's important for healthcare providers to be vigilant and assess the child's situation comprehensively to ensure their safety and well-being.
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