Which interventions would the nurse include in the plan of care for a patient with a diagnosis of bacterial meningitis?

Maintain the patient in a flat, supine position

Restrain the patient in bed.

Reduce the patient's environmental stimuli as much as possible

Increase the patient's fluid intake

Answer and Explanation

The Correct Answer is C

A.   A flat supine position is not recommended for patients with meningitis; they should be kept at a 30- degree angle to reduce ICP.

B.   Restraining the patient is unnecessary unless there is an immediate risk of harm, and it can cause distress.
C.   Reducing environmental stimuli helps minimize discomfort and risk of seizures, especially in meningitis, which causes hypersensitivity to light and sound.
D.   Fluid intake should be monitored carefully. Excessive fluids may increase ICP in a patient with meningitis.

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Correct Answer is B

Explanation

A. Placing the client in a supine position may increase ICP; the nurse should elevate the head of the bed to 30 degrees to reduce pressure.
B. Log rolling to reposition the client helps maintain spinal alignment and prevent further injury without increasing ICP.
C. Coughing and deep breathing should be avoided as they can increase ICP.
D. A warming blanket could cause vasodilation and worsen ICP.

A. "tPA should be administered within 12 hrs of the onset of a stroke." B. "tPA is administered by intraarterial infusion." C. "tPA is administered IV." D. "PA requires BP monitoring during and 24 hrs after the treatment."

Correct Answer is A

Explanation

A. tPA (tissue plasminogen activator) should be administered within 3 to 4.5 hours of the onset of ischemic stroke symptoms, not 12 hours. Administering it after this window increases the risk of complications such as bleeding.
B. tPA is administered by intraarterial infusion is true, but it refers to a specific technique for certain stroke types.
C. tPA is administered IV is correct for intravenous administration in many cases of ischemic stroke.

D. tPA requires BP monitoring during and 24 hrs after the treatment is accurate as blood pressure control is critical when administering tPA.

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Which interventions would the nurse include in the plan of care for a patient with a diagnosis of bacterial meningitis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed- head injury. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

An RN is teaching a student nurse about tissue plasminogen activator (tPA) administration in a patient with ischemic stroke. Which statement made by the student nurse indicates a need for further teaching?

Correct Answer is A

Explanation

Which intervention would the nurse implement as the priority when providing care for a patient with a ventriculostomy to measure increased intra-cranial pressure (ICP) caused by a brain tumor?

A nurse is developing a teaching plan for a client who has psoriasis. Which of the following actions should the nurse include in the plan?

A nurse is taking care of a client who has sustained a neurologic injury with increased intracranial pressure and decreased cerebral perfusion. Which of the following will keep cerebral perfusion pressure constant?

A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?

Which outcome would concern the nurse when the patient's calculated mean arterial pressure (MAP) is below 70 mm Hg?

A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure?

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication?