Exhibits
Drag 1 condition and 1 client finding to fill in each blank in the following sentence.
The client is at risk for developing
The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}
Rationale for Correct Choices:
- Seizures: The adolescent’s fever, headache, photophobia, and neck stiffness (resistance to flexion) are consistent with signs of meningitis, which can lead to seizures, especially in the setting of increased intracranial pressure. Seizures are a known complication of untreated or severe meningitis.
- Signs of meningeal irritation: The adolescent demonstrates classic signs of meningeal irritation, such as photophobia, severe headache, and neck stiffness, which suggest inflammation of the meninges. This is a key indicator of potential meningitis and the associated risk of seizures.
Rationale for Incorrect Choices:
- Lyme disease: While Lyme disease can cause neurological symptoms, including headache and fever, the absence of a characteristic erythema migrans rash or recent tick exposure makes it less likely.
- Constipation: Constipation is not a likely complication given the adolescent's current symptoms, which are focused on fever, headache, and neurological signs. It does not explain the risk for seizures.
- Mononucleosis: Although mononucleosis can cause fever and malaise, it typically does not present with neck stiffness, photophobia, or the acute onset of severe headache that is suggestive of meningitis. The symptoms in this case are more concerning for meningitis.
- Pneumonia: Pneumonia is unlikely given the absence of respiratory findings such as cough or difficulty breathing. The symptoms are more consistent with a central nervous system infection, like meningitis, than a respiratory infection.
- Fever: While fever is present in meningitis, it alone does not indicate the risk for seizures. It is the combination of fever, headache, photophobia, and meningeal signs that increases the risk for complications like seizures.
- Inability to eat and drink: The inability to eat and drink is likely a result of nausea and vomiting, which is common in many illnesses, including meningitis. However, it is not a direct indicator of the risk for seizures, which is more strongly linked to meningeal irritation.
- Respiratory findings: There are no significant respiratory symptoms, such as difficulty breathing or abnormal lung sounds, making respiratory findings irrelevant in this case. The adolescent’s symptoms are primarily neurological.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Hopscotch: Hopscotch typically requires the ability to hop on one foot and follow a structured set of rules, which may be too advanced for a 2-year-old. Toddlers are still developing coordination and motor skills, so activities like hopscotch are not age-appropriate.
B. Beginner sports: While toddlers can start developing coordination, organized sports (even beginner ones) usually require more advanced skills like following directions and teamwork, which may not be suitable for a 2-year-old.
C. Finger paints: Finger painting is an ideal activity for a 2-year-old. It encourages creativity, helps with fine motor skills, and is enjoyable for toddlers as they explore textures and colors. It is a developmentally appropriate form of play.
D. 30-piece puzzle: A 30-piece puzzle may be too complex for a 2-year-old. Toddlers typically enjoy simpler puzzles with larger pieces, which are easier for their developing fine motor skills and cognitive abilities. A simpler puzzle would be more appropriate.
Correct Answer is C
Explanation
A. Reinforce with the guardians to avoid discussing death with the child's siblings: Avoiding the discussion of death with the child's siblings can create confusion and anxiety. It's important to foster open communication and allow siblings to process their emotions about the situation in an age-appropriate manner.
B. Guide discussions with the child about death: Discussions about death should be handled delicately, considering the child’s age and understanding; this should be done in partnership with the family and healthcare providers.
C. Use a calm tone of voice when speaking with the child: A calm, reassuring tone of voice is essential when interacting with a child in palliative care. This helps provide comfort, reduces anxiety, and establishes a sense of safety for the child during a difficult time.
D. Encourage the guardians to seek a second opinion about their child's diagnosis:
Seeking a second opinion may be an option in some situations, but in the context of palliative care, the focus is typically on comfort and quality of life rather than pursuing further curative treatments.
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