The nurse is aware that cloudy cerebrospinal fluid most likely indicates:
No infection because cerebrospinal fluid is usually cloudy.
Bacterial meningitis.
Sepsis.
Viral meningitis.
The Correct Answer is B
Choice A reason: Cerebrospinal fluid is normally clear, not cloudy. Cloudiness indicates abnormalities like infection or blood. The statement that cerebrospinal fluid is usually cloudy is incorrect, as clarity is a hallmark of healthy fluid, making this choice scientifically inaccurate.
Choice B reason: Cloudy cerebrospinal fluid is a hallmark of bacterial meningitis, caused by pus from bacterial proliferation (e.g., Neisseria meningitidis). Neutrophils and bacteria increase fluid turbidity, reflecting severe meningeal inflammation, distinguishing it from viral meningitis, which typically produces clearer fluid.
Choice C reason: Sepsis is a systemic infection, not specific to cerebrospinal fluid. While it may accompany meningitis, cloudy cerebrospinal fluid directly indicates meningeal infection, not generalized sepsis, which affects blood and organs, making this a less precise diagnosis for the finding.
Choice D reason: Viral meningitis typically produces clear or slightly cloudy cerebrospinal fluid, as it causes less cellular debris than bacterial meningitis. Lymphocytic predominance in viral infections results in minimal turbidity, making this less likely than bacterial meningitis for cloudy fluid.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Polyuria is associated with hyperglycemia, as in diabetes, where excess glucose causes osmotic diuresis. Hypoglycemia (55 mg/dL) does not cause polyuria; instead, it triggers neurological symptoms like shakiness due to low brain glucose, making this an incorrect finding.
Choice B reason: Dry, flushed skin is typical of hyperglycemia or dehydration, not hypoglycemia. Low blood sugar (55 mg/dL) causes sympathetic activation, leading to sweating and pallor, not dry skin, as the body attempts to restore glucose levels, making this incorrect.
Choice C reason: Tachycardia is expected in hypoglycemia (55 mg/dL), as low glucose triggers sympathetic nervous system activation, releasing catecholamines like epinephrine. This increases heart rate to enhance blood flow and glucose delivery to the brain, a compensatory response to neuroglycopenia.
Choice D reason: Deep, rapid respirations (Kussmaul breathing) occur in diabetic ketoacidosis to compensate for metabolic acidosis, not hypoglycemia. A blood glucose of 55 mg/dL causes neurological symptoms like shakiness, not respiratory changes, making this an incorrect expected finding.
Correct Answer is C
Explanation
Choice A reason: Allowing an infant with a hip cast to stand risks disrupting the correction of developmental dysplasia, as weight-bearing can misalign the hip joint. The cast maintains proper positioning, and standing could cause joint instability, delaying healing and proper femoral head development.
Choice B reason: Latex balloons pose a choking hazard and risk allergic reactions in infants. They do not promote developmental dysplasia recovery or growth, as they provide no therapeutic stimulation. Visual stimuli are beneficial, but safe, age-appropriate toys are needed to support development.
Choice C reason: A small electronic toy stimulates cognitive and sensory development in a 10-month-old with a hip cast. It encourages fine motor skills and engagement, supporting developmental milestones like object exploration and cause-effect learning, which are critical despite mobility restrictions from the cast.
Choice D reason: Prompt diaper changes prevent skin breakdown, important in a casted infant, but do not directly promote growth and development. While hygiene prevents infections, it addresses physical care, not cognitive or motor milestones critical for developmental progress in this age group.
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