A nurse in the emergency department is evaluating a young adult client for bacterial meningitis. Which of the following actions should the nurse take as part of the focused assessment?
Tap the client's facial nerve and note any facial twitching.
Strike the client's patellar tendon with a percussion hammer and note any increase in response.
Gently elevate the client's head and note any nuchal rigidity.
Run a tongue blade on the outside of the client's sole and note any flaring of the toes.
The Correct Answer is C
Choice A reason: Tapping the client's facial nerve and noting any facial twitching is not a specific assessment for bacterial meningitis. This action is more related to evaluating facial nerve function and is not typically used to diagnose meningitis.
Choice B reason: Striking the client's patellar tendon with a percussion hammer and noting any increase in response is a test for reflexes, which may or may not be altered in bacterial meningitis. An increased response can be seen in various neurological conditions and is not specific to meningitis.
Choice C reason: Gently elevating the client's head and noting any nuchal rigidity is a key part of the focused assessment for bacterial meningitis. Nuchal rigidity, or stiffness of the neck, is a classic sign of meningitis and is assessed by gently lifting the head and attempting to move the chin toward the chest. If the client resists due to pain or stiffness, this could indicate nuchal rigidity associated with meningitis.
Choice D reason: Running a tongue blade on the outside of the client's sole and noting any flaring of the toes, known as the Babinski sign, is used to assess for central nervous system lesions and is not specific to meningitis. While it can be part of a neurological assessment, it does not specifically indicate bacterial meningitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Rinse your mouth with hydrogen peroxide
Rinsing the mouth with hydrogen peroxide is not recommended for clients with mucositis. Hydrogen peroxide can be too harsh and may cause further irritation to the already sensitive mucosal lining. It is generally advised to use mild rinses such as saline or baking soda solutions.
Choice B: Brush your teeth for 60 seconds twice daily
While brushing is important, it should be done gently with a soft-bristled toothbrush, and the timing should be based on patient tolerance rather than a strict 60-second rule.
Choice C: Floss your teeth gently following each meal
Gentle flossing helps remove food particles and bacteria, reducing the risk of infection. However, if bleeding occurs, the patient should stop and consult a healthcare provider.
Choice D: Wear your dentures only during meals
Wearing dentures only during meals might be advisable for some clients with mucositis, as wearing them all day could irritate the inflamed oral tissues. However, it’s important for the dentures to fit properly and for the client to have periods of rest without the dentures to allow the oral tissues to heal.
Correct Answer is B
Explanation
Choice A reason: Telling a family to limit discussing past events with the client may not be culturally sensitive. Each culture has its own views on reminiscing and sharing memories, especially during end-of-life care. Some cultures value the sharing of stories and memories as a way to honor the individual's life.
Choice B reason: Saying "We will respect what is important to you" is a statement that acknowledges and incorporates the client's and family's cultural beliefs. It shows a willingness to understand and prioritize their values, customs, and preferences in the care plan. This approach is aligned with culturally competent care, which is crucial in hospice settings.
Choice C reason: Offering to arrange all burial services may overstep boundaries, as burial practices are deeply rooted in cultural and religious beliefs. It is important for healthcare providers to discuss and understand the family's wishes and provide support in accordance with their specific cultural practices.
Choice D reason: Advising that grieving should not be done in front of the client may not align with the family's cultural beliefs about expressing emotions and grief. Different cultures have varied expressions of grief, and it is essential to respect these practices. Some cultures view the open expression of grief as an important part of the mourning process.
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