A client presents with the onset of a severe headache, fever, nuchal rigidity, and a petechial rash on arms and legs. The nurse recognizes the client is exhibiting symptoms of which condition?
Rocky Mountain spotted fever.
Intracerebral hemorrhage.
Cerebrovascular accident (CVA).
Meningococcal meningitis.
The Correct Answer is D
Choice A reason: Rocky Mountain spotted fever is not the most likely condition for the client who has a severe headache, fever, nuchal rigidity, and a petechial rash on arms and legs. Rocky Mountain spotted fever is a bacterial infection transmitted by ticks that causes a distinctive rash that usually begins on the wrists and ankles and spreads to the rest of the body. The rash is not limited to the arms and legs, and the client may also have other symptoms such as nausea, vomiting, abdominal pain, and muscle aches.
Choice B reason: Intracerebral hemorrhage is not the most likely condition for the client who has a severe headache, fever, nuchal rigidity, and a petechial rash on arms and legs. Intracerebral hemorrhage is a type of stroke that occurs when a blood vessel bursts inside the brain, causing bleeding and swelling. The rash is not a typical sign of intracerebral hemorrhage, and the client may also have other symptoms such as weakness, numbness, vision loss, confusion, and loss of consciousness.
Choice C reason: Cerebrovascular accident (CVA) is not the most likely condition for the client who has a severe headache, fever, nuchal rigidity, and a petechial rash on arms and legs. CVA is another term for stroke, which occurs when the blood supply to a part of the brain is interrupted, causing brain tissue damage. The rash is not a common sign of CVA, and the client may also have other symptoms such as facial drooping, slurred speech, difficulty swallowing, paralysis, and cognitive impairment.
Choice D reason: Meningococcal meningitis is the most likely condition for the client who has a severe headache, fever, nuchal rigidity, and a petechial rash on arms and legs. Meningococcal meningitis is a bacterial infection that causes inflammation of the membranes that cover the brain and spinal cord. The rash is a characteristic sign of meningococcal meningitis, which can appear as small red or purple spots that do not fade when pressed. The client may also have other symptoms such as nausea, vomiting, sensitivity to light, confusion, and seizures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}
Explanation
a) Denies cramps, weakness, or nausea
This finding indicates that the actions taken were effective in relieving the patient's symptoms of fatigue, weakness, muscle cramps, and nausea. These symptoms may have been caused by electrolyte imbalances, dehydration, or infection related to her ESRD and missed dialysis sessions.
b) BP 116/68 mm Hg, HR 75 bpm
This finding indicates that the actions taken were effective in lowering the patient's blood pressure and heart rate. The patient had a history of HTN and CAD and presented with elevated BP and HR in the ED. The orders for EKG, cardiac monitor, chest X-ray, and echocardiogram may have helped to assess and manage her cardiac status. The patient may have also received antihypertensive medications or fluids as part of her treatment.
c) Potassium level 3.6 mEq/L (3.6 mmol/L)
This finding indicates that the actions taken were effective in normalizing the patient's potassium level. The patient had ESRD and missed dialysis sessions, which could have resulted in hyperkalemia or hypokalemia. The orders for basic metabolic panel and blood cultures may have helped to monitor and correct her electrolyte levels. The patient may have also received potassium supplements or binders as part of her treatment.
d) Verbalizes commitment to dialysis appointments
This finding indicates that the actions taken were effective in educating and motivating the patient to adhere to her dialysis schedule. The patient had ESRD and missed dialysis sessions, which could have worsened her condition and increased her risk of complications. The orders for CT scan of abdomen and echocardiogram may have helped to evaluate her renal function and cardiac function. The patient may have also received counseling or support from the health care team as part of her treatment.
e) Client states that she will need to resume her Lisinopril to control blood pressure
This finding indicates that the actions taken were ineffective in teaching the patient about her medication regimen. The patient had a history of HTN and CAD and was prescribed Lisinopril as an antihypertensive medication. However, Lisinopril is contraindicated in patients with ESRD as it can cause hyperkalemia or worsen renal function. The patient should be informed about the potential risks of taking Lisinopril and advised to consult with her nephrologist or primary care provider before resuming it.
f) Client is eager to add dark green vegetables and potatoes to her diet
This finding indicates that the actions taken were ineffective in educating the patient about her dietary restrictions. The patient had ESRD and required hemodialysis three times a week. She should follow a renal diet that limits the intake of potassium, phosphorus, sodium, and fluid. Dark green vegetables and potatoes are high in potassium and phosphorus and should be avoided or consumed in moderation by patients with ESRD. The patient should be provided with a list of foods that are suitable for her condition and referred to a dietitian for further guidance.
Correct Answer is ["A","B","C"]
Explanation
Choice A reason: Presenting a calm, supportive demeanor is an appropriate intervention for a client who is experiencing anxiety and hallucinations. The nurse should use a soothing tone of voice, maintain eye contact, and avoid arguing or challenging the client's perceptions. This can help reduce the client's agitation and promote trust.
Choice B reason: Reorienting to day and time frequently is an appropriate intervention for a client who is experiencing anxiety and hallucinations. The nurse should provide reality-based information and reminders about the client's situation, such as the reason for hospitalization, the name of the nurse, and the expected plan of care. This can help the client regain a sense of orientation and control.
Choice C reason: Administering an as needed (PRN) dose of lorazepam is an appropriate intervention for a client who is experiencing anxiety and hallucinations. Lorazepam is a benzodiazepine that can reduce anxiety, agitation, and psychotic symptoms by enhancing the effects of gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter in the brain. The nurse should monitor the client's vital signs, level of sedation, and risk of falls after giving the medication.
Choice D reason: Turning the television on for distraction is not an appropriate intervention for a client who is experiencing anxiety and hallucinations. The television can increase the sensory stimulation and confusion for the client, and may worsen the hallucinations or delusions. The nurse should provide a quiet and safe environment for the client.
Choice E reason: Applying soft wrist restraints bilaterally is not an appropriate intervention for a client who is experiencing anxiety and hallucinations. Restraints can increase the anxiety and agitation for the client, and may cause physical or psychological harm. The nurse should use restraints only as a last resort when other less restrictive measures have failed to protect the client or others from harm.
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