The nurse is assessing a client who is reporting a severe headache. During the physical assessment, which finding should the nurse interpret as a possible indication of meningitis?

Nuchal rigidity.

Lethargy.

Hyperglycemia.

Left flank pain.

Answer and Explanation

The Correct Answer is A

Rationale:
A. Nuchal rigidity: Nuchal rigidity reflects meningeal irritation caused by inflammation of the meninges. Neck stiffness occurs due to pain and resistance when attempting neck flexion. It is a classic physical finding associated with meningitis and warrants immediate evaluation.

B. Lethargy: Lethargy may occur with many conditions including infection, metabolic disturbances, or medication effects. While it can accompany meningitis, it is nonspecific and not a defining physical sign. It does not directly indicate meningeal inflammation.

C. Hyperglycemia: Elevated blood glucose is related to endocrine or stress responses rather than central nervous system infection. It does not reflect meningeal involvement or intracranial inflammation. Hyperglycemia is not associated with meningitis diagnosis.

D. Left flank pain: Flank pain suggests renal or musculoskeletal pathology rather than neurologic or meningeal disease. It is unrelated to meningeal inflammation. This finding does not support suspicion of meningitis.

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Correct Answer is B

Explanation

Rationale:
A. Position the client's head facing away from the site: While proper positioning can reduce infection risk and ensure comfort, it does not verify catheter patency or safety for medication administration.

B. Aspirate for the presence of a blood return: Before administering medication through a central venous catheter, the nurse must confirm patency by aspirating for a blood return. This ensures the catheter is in the vessel lumen and reduces the risk of extravasation or complications such as thrombosis.

C. Prepare a saline flush in a three mL syringe: While a saline flush is required, it should be administered only after patency is confirmed. Using a small syringe may reduce the risk of excessive pressure, but confirming blood return is the first step.

D. Initiate an infusion of 0.9% normal saline solution: Starting a saline infusion may maintain catheter patency, but it does not confirm that the line is safe for immediate medication administration. Patency verification must precede fluid or drug administration.

A. New-onset agitation B. Slurred speech C. Disorientation to place and events D. Pain rating of 4 on a 0 to 10 scale E. History of recent exploratory laparotomy F. Stable vital signs within expected ranges

Correct Answer is ["A","B","C"]

Explanation

Rationale:
A. New-onset agitation: Acute agitation in a previously alert and oriented postoperative trauma client raises concern for neurologic compromise, hypoxia, intracranial injury, or evolving delirium. Sudden mental status changes are never expected findings and require immediate assessment before transfer. Early recognition is critical to prevent deterioration.

B. Slurred speech: Slurred speech suggests possible neurologic dysfunction involving cerebral perfusion, cranial nerves, or central nervous system injury. In the context of recent trauma, this finding raises concern for delayed intracranial bleeding or metabolic disturbance. This represents a time-sensitive neurologic red flag.

C. Disorientation to place and events: Acute disorientation indicates an alteration in cognitive function and may reflect delirium, hypoxia, infection, or neurologic injury. A sudden loss of orientation after a period of normal mentation is abnormal and requires prompt investigation. Transfer should be delayed until the cause is identified.

D. Pain rating of 4 on a 0 to 10 scale: A pain level of 4 is mild to moderate and expected following abdominal surgery. The pain was appropriately treated earlier with ibuprofen and does not represent an acute change. This finding does not require immediate intervention prior to transfer.

E. History of recent exploratory laparotomy: A recent laparotomy is a known and stable part of the client’s medical history. The abdominal assessment shows normal postoperative findings with bowel sounds present and a dry, intact dressing. This alone does not explain the acute neurologic changes.

F. Stable vital signs within expected ranges: The client’s vital signs remain within normal limits and show no evidence of hemodynamic instability. Stable vital signs do not exclude serious neurologic pathology. Neurologic deterioration can occur despite normal vital signs and must be prioritized.

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The nurse is assessing a client who is reporting a severe headache. During the physical assessment, which finding should the nurse interpret as a possible indication of meningitis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is ["A","B","C"]

Explanation

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