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 D

Explanation

A. BP 126/54 mm Hg, pulse 58 beats/min, respirations 10 breaths/min - While the low pulse and respirations should be assessed, this blood pressure isn't as concerning.
B. BP 112/56 mm Hg, pulse 98 beats/min, respirations 28 breaths/min - These vital signs are within a safer range compared to the critical changes in D.
C. BP 129/65 mm Hg, pulse 60 beats/min, respirations 20 breaths/min - These are stable vital signs.
D. The BP of 172/54 mm Hg, combined with bradycardia (pulse of 58 beats/min) and hypoventilation (respirations of 10 breaths/min), is indicative of Cushing's triad, a late sign of increased intracranial pressure, which is an emergency requiring immediate attention.

A. Establish the ability to communicate effectively. B. Learn to control impulsive behavior. C. Improve left-side motor function. D. Compensate for loss of depth perception.

Correct Answer is A

Explanation

A. Left-sided strokes commonly affect language and speech functions due to damage in the language center, so communication goals should be prioritized.
B. Impulsive behavior is more commonly associated with right-sided strokes, not left-sided strokes.
C. Left-sided motor deficits are due to the right hemisphere being affected, not the left hemisphere.
D. Loss of depth perception is more often seen with right-sided strokes, affecting the right hemisphere.

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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

When the patient's initial vital signs after a brain injury were a BP of 132/72 mm Hg, pulse 100 beats/min, respirations 24 breaths/min, which subsequent vital signs would the nurse report immediately to the health care provider?

Correct Answer is D

Explanation

A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program?

Correct Answer is A

Explanation

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

After performing an assessment of the oculocephalic reflex, the nurse suspects that the patient has an intracranial lesion. Which patient behavior supports the nurse's assessment findings?

A nurse is teaching about risk factors for developing a stroke with a group of older adult clients. Which of the following nonmodifiable risk factors should the nurse include?

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 has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?

A nurse is caring for a client who has increased intracranial pressure and has a worsening neurologic condition. Which of the following cues should the nurse recognize as a worsening condition? (Select All that Apply.)

A nurse is teaching an older adult client who has diabetes mellitus about preventing the long- term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include?