A nurse is assisting with the admission of an adolescent client who is suspected to have bacterial meningitis. Which of the following findings should the nurse expect?
2+ pedal edema
Jaundice
Nuchal rigidity
Hematuria
The Correct Answer is C
Bacterial meningitis is a serious infection of the membranes surrounding the brain and spinal cord that can cause inflammation and damage to the nervous system.
Nuchal rigidity refers to stiffness and pain in the neck that makes it difficult to flex the neck forward. This finding is indicative of inflammation of the meninges and is a classic sign of meningitis.
Pedal edema refers to swelling of the feet and ankles and can be caused by various conditions such as heart, liver, or kidney problems.
Jaundice refers to yellowing of the skin and eyes and can be caused by liver or bile duct disease.
Hematuria refers to the presence of blood in the urine and can be caused by various conditions such as urinary tract infections, kidney stones, or bladder cancer. These findings are not related to bacterial meningitis and may suggest other health concerns that require further evaluation and management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A.While monitoring the client's physical condition, including range of motion, is important, it typically needs to be done more frequently than every 60 minutes. The Joint Commission and other regulatory bodies often recommend continuous observation and checks every 15 minutes.
B.Typically, a provider's order for restraints must be obtained immediately or within a very short time frame (often within an hour), not 48 hours. Regulations vary but generally require prompt notification and authorization.
C.Restraints should only be used as a last resort and for the shortest duration possible. The goal is to ensure the client's safety and the safety of others while minimizing the use of restraints. Removing the restraints as soon as the client is calm and no longer a threat to themselves or others is essential to respecting the client's rights and promoting their dignity.
D.Offer the client a nutritious snack every 4 hr.: While providing nutrition and hydration is important, the primary focus immediately after applying restraints should be on the client's safety and the frequent assessment of their condition. Offering a snack every 4 hours is not the immediate priority in this context.
Correct Answer is B
Explanation
It is important for the nurse to acknowledge the client's fears and show empathy toward them. By saying "This must be very frightening for you," the nurse validates the client's feelings and shows that they are being heard. Additionally, by suggesting that they talk more about it, the nurse can work towards building a therapeutic relationship with the client and gain more insight into their thought processes.
The other options are not appropriate because:
a. The nurse should not deny the client's beliefs or try to convince them that they are wrong. This can cause
the client to feel invalidated which may make them less likely to trust the nurse.
c. While it is important to understand the client's perspective, this question may come off as confrontational and accusatory.
d. Similarly, this question may be perceived as confrontational and may make the client defensive. It is important to approach the client with empathy and understanding rather than skepticism.
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