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 B
Explanation
Choice A reason: Sweet potatoes are not a food that the client should avoid after passing a calcium oxalate renal stone, because they are low in oxalate, which is a substance that can combine with calcium in the urine and form stones. The client should limit foods that are high in oxalate, such as spinach, rhubarb, beets, nuts, chocolate, tea, and wheat bran. Therefore, this choice is incorrect.
Choice B reason: Spinach salad is a food that the client should avoid after passing a calcium oxalate renal stone, because it is high in oxalate, which can increase the risk of stone formation. The client should consume foods that are low in oxalate, such as rice, corn, apples, grapes, peaches, and cheese. Therefore, this choice is correct.
Choice C reason: Bananas are not a food that the client should avoid after passing a calcium oxalate renal stone, because they are low in oxalate and high in potassium, which can help prevent stone formation. The client should increase the intake of fluids, calcium, and citrate, which can reduce the concentration of oxalate and calcium in the urine and inhibit stone formation. Therefore, this choice is incorrect.
Choice D reason: Fish is not a food that the client should avoid after passing a calcium oxalate renal stone, because it is low in oxalate and high in protein, which can help maintain muscle mass and prevent weight loss. The client should moderate the intake of animal protein, such as meat, poultry, eggs, and dairy products, which can increase the acidity of the urine and promote stone formation. Therefore, this choice is incorrect.
Correct Answer is D
Explanation
Choice A reason: This is incorrect because performing a complete mental status exam is not a relevant or appropriate action for the nurse to implement. A mental status exam is used to evaluate the client's cognitive, emotional, and behavioral functioning, but it does not address the client's physical pain or its underlying cause.
Choice B reason: This is incorrect because determining if the client has had a shingles vaccination is not a priority or helpful action for the nurse to implement. A shingles vaccination is recommended for people who are 50 years or older to prevent or reduce the severity of shingles, but it does not affect the occurrence or treatment of postherpetic neuralgia, which is a chronic pain condition that can develop after shingles.
Choice C reason: This is incorrect because teaching the client about phantom pain symptoms is not an accurate or useful action for the nurse to implement. Phantom pain is a type of neuropathic pain that occurs when a person feels pain in a body part that has been amputated or removed. However, this is not the case for the client who has pain in the area where the shingles rash occurred.
Choice D reason: This is correct because completing an assessment of the client's pain is the most important action for the nurse to implement. Pain assessment involves collecting information about the location, intensity, quality, duration, frequency, and aggravating or relieving factors of the pain, as well as its impact on the client's daily activities and quality of life. This can help the nurse identify the cause and severity of the pain, as well as plan and evaluate appropriate interventions.
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