The nurse is caring for a client who is diagnosed with bacterial meningitis. Which assessment finding would be an immediate concern for the nurse?

Periodic nystagmus

Severe unrelenting headaches

Photophobia during the day

Decreased level of consciousness

Answer and Explanation

The Correct Answer is D

Choice A: Periodic Nystagmus

Nystagmus, which is characterized by involuntary eye movements, can be a symptom of various neurological conditions, including bacterial meningitis. However, it is not typically an immediate concern compared to other symptoms. Nystagmus indicates potential issues with the brainstem or cerebellum, but it does not directly threaten the patient’s life or indicate a rapid deterioration in condition. Therefore, while it is important to monitor, it is not the most urgent finding.

Choice B: Severe Unrelenting Headaches

Severe headaches are a common symptom of bacterial meningitis due to the inflammation of the meninges. While they are extremely painful and distressing for the patient, they are not as immediately life-threatening as a decreased level of consciousness. Headaches indicate increased intracranial pressure, which is serious, but the priority is to address symptoms that indicate a more rapid decline in neurological function.

Choice C: Photophobia During the Day

Photophobia, or sensitivity to light, is another common symptom of meningitis. It results from the irritation of the meninges and is often accompanied by headaches. While photophobia can be very uncomfortable and indicative of meningitis, it is not an immediate concern compared to a decreased level of consciousness. Photophobia does not directly indicate a life-threatening situation.

Choice D: Decreased Level of Consciousness

A decreased level of consciousness is the most immediate concern for a nurse caring for a patient with bacterial meningitis. This symptom indicates a significant and potentially rapid decline in the patient’s neurological status. It can be a sign of increased intracranial pressure, brain swelling, or other severe complications. Immediate medical intervention is required to prevent further deterioration and potential fatality. Monitoring and addressing changes in consciousness are critical in managing bacterial meningitis effectively.

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Correct Answer is ["31"]

Explanation

Step 1: Calculate the total infusion time in minutes.

8 hours × 60 minutes/hour = 480 minutes

Result at each step = 480 minutes

Step 2: Calculate the total number of drops to be infused.

1,000 mL × 15 drops/mL = 15,000 drops

Result at each step = 15,000 drops

Step 3: Calculate the infusion rate in drops per minute.

15,000 drops ÷ 480 minutes = 31.25 drops/minute

Result at each step = 31.25 drops/minute

Step 4: Round to the nearest whole number if necessary.

31.25 drops/minute rounds to 31 drops/minute

Result at each step = 31 drops/minute

Therefore, the nurse should run the IV infusion at a rate of 31 drops per minute.

A. Instruct the patient to withhold any medication for diuretic therapy. B. Prepare to administer fluids 2 hours before the procedure for patients with renal dysfunction. C. Advise the patient to take all anticoagulants. D. Administer steroids if the patient has an allergy to iodine-based contrast. E. Ensure that the patient is NPO for a minimum of 2 hours before the procedure.

Correct Answer is ["A","C","D","E"]

Explanation

Choice A: Instruct the patient to withhold any medication for diuretic therapy.

Reason: Diuretics can lead to dehydration and electrolyte imbalances, which can complicate the cardiac catheterization procedure. Withholding diuretics helps to maintain fluid balance and reduce the risk of complications during the procedure

Choice B: Prepare to administer fluids 2 hours before the procedure for patients with renal dysfunction.

Reason: Administering fluids before the procedure helps to prevent contrast-induced nephropathy, especially in patients with renal dysfunction. Hydration helps to flush out the contrast material used during the procedure, reducing the risk of kidney damage.

Choice C: Advise the patient to take all anticoagulants.

Reason: This choice is incorrect. Patients are usually advised to withhold anticoagulants before a cardiac catheterization to reduce the risk of bleeding complications. The decision to continue or withhold anticoagulants should be based on a careful assessment of the patient’s risk of thromboembolism versus the risk of bleeding.

Choice D: Administer steroids if the patient has an allergy to iodine-based contrast.

Reason: Administering steroids is a common premedication strategy for patients with a known allergy to iodine-based contrast media. Steroids help to reduce the risk of an allergic reaction during the procedure.

Choice E: Ensure that the patient is NPO for a minimum of 2 hours before the procedure.

Reason: Ensuring that the patient is NPO (nothing by mouth) helps to reduce the risk of aspiration during the procedure. Typically, patients are advised to be NPO for 6-8 hours before the procedure, but a minimum of 2 hours is essential.

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The nurse is caring for a client who is diagnosed with bacterial meningitis. Which assessment finding would be an immediate concern for the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits You retrieved regular insulin 100 units in 1 ml. How many ml should you administer? Note Enter ONLY the number DO NOT enter the unit(s) of measurement

Correct Answer is ["31"]

Explanation

In addition to assessing peripheral pulses and auscultating the patient’s heart and lung sounds, which action will be implemented by the nurse before a cardiac catheterization? Select all that apply. One, some, or all responses may be correct.

Correct Answer is ["A","C","D","E"]

Explanation

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