The nurse is caring for a patient with bacterial meningitis caused by Haemophilus influenzae type B. What should the nurse include in the patient's plan of care?

Monitoring of neurologic status

Infusion of large volumes of isotonic intravenous fluids

Standard precautions

Distraction activities to reduce long periods of sleep.

Answer and Explanation

The Correct Answer is A

Choice A reason: This is correct. Monitoring of neurologic status is a priority intervention for a patient with bacterial meningitis, as the infection can cause inflammation and damage to the brain and spinal cord. The nurse should assess the patient's level of consciousness, pupillary response, cranial nerve function, and signs of increased intracranial pressure.

Choice B reason: This is incorrect. Infusion of large volumes of isotonic intravenous fluids is not indicated for a patient with bacterial meningitis, as it can worsen the cerebral edema and increase the intracranial pressure. The patient should receive adequate hydration, but not excessive fluids.

Choice C reason: This is incorrect. Standard precautions are not sufficient for a patient with bacterial meningitis, as the infection can be transmitted through respiratory droplets. The patient should be placed on droplet precautions, which include wearing a mask, gloves, and gown, and limiting the contact with other patients and visitors.

Choice D reason: This is incorrect. Distraction activities to reduce long periods of sleep are not appropriate for a patient with bacterial meningitis, as the patient may need rest and sedation to reduce the agitation and pain. The nurse should provide a quiet and dark environment, and avoid unnecessary stimuli that can increase the intracranial pressure.

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Correct Answer is D

Explanation

Choice A reason: This is incorrect. Generalized muscle weakness and severe muscle spasms are not late manifestations of amyotrophic lateral sclerosis, but rather early or intermediate symptoms. Amyotrophic lateral sclerosis is a progressive neurodegenerative disorder that affects the motor neurons that control voluntary muscles. The disease causes muscle weakness, stiffness, twitching, and cramps.

Choice B reason: This is incorrect. Mental confusion and aggressive behaviors are not common manifestations of amyotrophic lateral sclerosis, but rather signs of dementia or other psychiatric disorders. Amyotrophic lateral sclerosis does not usually affect the cognitive or emotional functions of the brain, except in some rare cases.

Choice C reason: This is incorrect. Dysarthria and decreased clarity of spoken words are not late manifestations of amyotrophic lateral sclerosis, but rather intermediate or advanced symptoms. Dysarthria is a speech disorder that results from the weakness or paralysis of the muscles involved in speech production. It causes slurred, slow, or distorted speech.

Choice D reason: This is correct. Impairment of respiratory muscles and cognition remains intact are common late manifestations of amyotrophic lateral sclerosis. As the disease progresses, the respiratory muscles become weak and unable to support breathing. This can lead to respiratory failure and death. However, the cognition of the patient usually remains intact until the end, as the disease does not affect the higher functions of the brain.

A. Patient sways from side-to-side when standing with feet close together. B. Patient's pupils do not respond equally to direct light from a flashlight. C. Patient takes two attempts to touch their nose while their eyes are closed. D. Patient complains of mild dizziness.

Correct Answer is A

Explanation

Choice A reason:Swaying during a Romberg test indicates a positive result, suggesting proprioceptive deficits or sensory ataxia.

Choice B reason:Unequal pupil response to light relates to cranial nerve function, not balance assessed by the Romberg test.

Choice C reason: This is incorrect. Patient taking two attempts to touch their nose while their eyes are closed is a mild impairment of coordination, which may be due to neurologic changes or other factors such as fatigue or medication. This is not a significant finding that requires immediate attention.

Choice D reason: This is incorrect. Patient complaining of mild dizziness is a common symptom of neurologic changes or vestibular dysfunction. It is not a serious finding that requires immediate attention. The nurse should monitor the patient and provide comfort measures.

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The nurse is caring for a patient with bacterial meningitis caused by Haemophilus influenzae type B. What should the nurse include in the patient's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching the family about amyotrophic lateral sclerosis and progression of the disease. The nurse would include which common late manifestations?

Correct Answer is D

Explanation

The nurse completes a Romberg's test on a patient with neurologic changes. The nurse will notify the provider if they observe which response?

Correct Answer is A

Explanation

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The nurse is caring for a patient with bacterial meningitis caused by Haemophilus influenzae type B. What should the nurse include in the patient's plan of care?