What is the first action a nurse should take when bacterial meningitis is suspected in a client?

Initiate isolation precautions

Administer antibiotics after collecting cultures

Prepare for a lumbar puncture after ruling out increased ICP

Start IV fluid

Answer and Explanation

The Correct Answer is A

A. Initiate isolation precautions — This is the first action the nurse should take. Bacterial meningitis is highly contagious (often spread via droplet transmission), and immediate isolation (droplet precautions) helps prevent spread to others.
B. Administer antibiotics after collecting cultures — This is a critical next step, but only after the client is placed in isolation to protect others.
C. Prepare for a lumbar puncture after ruling out increased ICP — While a lumbar puncture is important for diagnosis, increased ICP must be ruled out first, and this is not the immediate first action.
D. Start IV fluids — Supportive care is important, but it is not the priority over infection control measures.

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Correct Answer is D

Explanation

A. A heart murmur may or may not be present but is not a specific sign of right-sided heart failure.
B. Shoulder pain radiating to the jaw is more indicative of cardiac ischemia or angina, not right-sided heart failure.
C. Crackles in the lungs are associated with left-sided heart failure due to pulmonary congestion.
D. Peripheral edema is a hallmark sign of right-sided heart failure, caused by systemic venous congestion and fluid accumulation in tissues.

A. Arms flexed at the elbows, with the hands and wrists bent toward the chest B. Grimacing in pain when the neck is flexed, causing the legs to bend at the knee C. The nurse is unable to extend the leg when the hip is flexed without causing the patient to grimace in pain D. Arms extended, rigidly held straight out with palms of the hands turned away from the body

Correct Answer is A

Explanation

A. Decorticate posturing is characterized by arms flexed at the elbows with wrists and fingers bent inward toward the chest, indicating damage to the cerebral hemispheres or corticospinal tract.
B. Grimacing and leg movement with neck flexion describe a positive Brudzinski’s sign, related to meningeal irritation, not posturing.
C. Inability to extend the leg with hip flexion causing pain describes a positive Kernig’s sign, also related to meningeal irritation.
D. Arms extended and rigid with palms turned outward describe decerebrate posturing, indicating more severe brainstem injury.

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What is the first action a nurse should take when bacterial meningitis is suspected in a client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

An acute care nurse receives a shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client?

Correct Answer is A

Explanation

A patient is experiencing increased afterload. How would this condition likely impact the heart structure over time?

Which of the following is a common symptom of meningitis?

What happens in stage four of intracranial pressure?

A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect?

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?

A nurse is preparing to administer digoxin to a client who has heart failure. Which of the following actions is appropriate?

A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following instructions should the nurse include in the teaching?

A nurse notes an increased heart rate in a patient with heart failure. Which compensatory mechanism is likely at play?