A nurse is caring for an adolescent who was brought to the emergency department (ED) with a high fever, headache, and neck stiffness. The nurse reviews the adolescent's cerebrospinal fluid (CSF) analysis results and notes the following:
- WBC count 300 cells/microliter (normal range: 0 to 10 cells/microliter)
- Protein 45 mg/dL (normal range: 15 to 45 mg/dL)
- Glucose 40 mg/dL (normal range: 50 to 75 mg/dL)
- Color Turbid (normal: clear and colorless)
The nurse should suspect that the adolescent has which of the following conditions?
Bacterial meningitis.
Viral meningitis.
Encephalitis.
Brain abscess.
The Correct Answer is A
Choice A reason: Bacterial meningitis is a probable condition, as it is an infection of the membranes that cover the brain and spinal cord, caused by various bacteria, such as Streptococcus pneumoniae, Neisseria meningitidis, or Haemophilus influenzae. The adolescent has many signs and symptoms of bacterial meningitis, such as fever, headache, and neck stiffness.
Choice B reason: Viral meningitis is not a likely condition, as it is an infection of the membranes that cover the brain and spinal cord, caused by various viruses, such as enteroviruses, herpes simplex virus, or mumps virus. The adolescent has some signs and symptoms of viral meningitis, such as fever, headache, and neck stiffness, but they are usually less severe than bacterial meningitis.
Choice C reason: Encephalitis is not a probable condition, as it is an inflammation of the brain tissue, usually caused by viral infections, such as herpes simplex virus, West Nile virus, or rabies virus. The adolescent has some signs and symptoms of encephalitis, such as fever, headache, and altered mental status, but they are usually accompanied by focal neurological deficits, such as seizures, paralysis, or cranial nerve palsies.
Choice D reason: Brain abscess is not a definite condition, as it is a collection of pus within the brain tissue, usually caused by bacterial infections that spread from other parts of the body, such as the ear, sinus, or lung. The adolescent has some signs and symptoms of brain abscess, such as fever, headache, and altered mental status, but they are usually accompanied by focal neurological deficits, such as seizures, paralysis, or cranial nerve palsies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Promising not to tell anyone about the abuse is not a helpful statement, as it implies that the abuse is a secret that should be hidden. This may make the child feel ashamed, guilty, or isolated. The nurse has a duty to report the abuse to the proper authorities and to protect the child from further harm.
Choice B reason: Blaming the family for the abuse is not a helpful statement, as it may cause the child to feel conflicted, angry, or fearful. The child may still love the family member who abused them, or may depend on them for their basic needs. The nurse should avoid making judgments or accusations, and instead focus on the child's feelings and safety.
Choice C reason: Reassuring the child that the abuse is not their fault is a helpful statement, as it may help the child cope with the trauma and reduce the feelings of self-blame, guilt, or shame. The nurse should validate the child's emotions and let them know that they are not responsible for the abuse or for stopping it.
Choice D reason: Suggesting to discuss the abuse with the family is not a helpful statement, as it may put the child in danger or cause them more distress. The child may not feel comfortable or safe to talk about the abuse with the family member who abused them, or with other family members who may not believe them or support them. The nurse should respect the child's privacy and boundaries, and only involve the family with the child's consent and under professional guidance.
Correct Answer is D
Explanation
Choice A reason: Maintaining the infant in the supine position is not an appropriate intervention, as it can increase the pressure on the myelomeningocele sac and cause further damage to the spinal cord. The nurse should position the infant prone or side-lying, with the head turned to one side and the hips flexed.
Choice B reason: Limiting visitors to immediate family members is not a necessary intervention, as the infant does not have an infectious condition that requires isolation. The nurse should encourage the parents and other family members to visit and bond with the infant, and provide emotional support and education.
Choice C reason: Initiating contact precautions is not a required intervention, as the infant does not have a contagious condition that poses a risk of transmission to others. The nurse should follow standard precautions, such as washing hands, wearing gloves, and disposing of contaminated materials properly.
Choice D reason: Providing a latex-free environment is an essential intervention, as the infant has a high risk of developing a latex allergy due to the frequent exposure to latex products during surgery and other procedures. The nurse should avoid using latex gloves, catheters, syringes, bandages, or other items that contain latex, and use alternative materials instead. The nurse should also label the infant's chart, crib, and door with a latex allergy alert.
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