A nurse is caring for a 30-year-old client who was brought to the emergency department (ED).

Exhibits

The nurse should determine the assessment findings are consistent with which of the following disease processes?

For each assessment finding, click to specify if the finding is consistent with bacterial meningitis or encephalitis. Each finding may support more than 1 disease process.

WBC count in CSF

Muscle weakness

Altered level of consciousness

Kernig sign result

Body temperature at 2105

Answer and Explanation

The Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A"},"E":{"answers":"A,B"}}

A high white blood cell (WBC) count in cerebrospinal fluid (CSF) is more commonly associated with bacterial meningitis, characterized by a high neutrophil count, low glucose, and high protein levels. it is also seen in encephalitis and reflects the individual cell lines that are affected.

Muscle weakness and altered levels of consciousness can occur in both conditions but are more prominent in encephalitis, which often presents with focal neurological deficits and seizures. The

Kernig sign, a classical sign of meningitis, is a physical examination finding that indicates irritation of the meninges and supports a diagnosis of bacterial meningitis when positive.

An elevated body temperature is common in bacterial meningitis, but it is not exclusive and can be observed in encephalitis as well.

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Free Nursing Study Resources

Correct Answer is ["33"]

Explanation

To calculate the infusion rate, we'll use the following formula:

Infusion rate (gtt/min) = (Volume to be infused (mL) / Time (min)) ) x Drop factor (gtt/mL)

First, calculate the total volume to be infused:

100 mL / 30 min = 3.33 mL/min

Then, multiply the volume per minute by the drop factor:

3.33 mL/min x 10 gtt/mL = 33.3 gtt/min

Therefore, the nurse should set the manual IV infusion to deliver 33 gtt/min.

A. Instruct the assistive personnel (AP) to focus on clients' activities of daily living (ADLs). B. Focus on providing care to clients with life-threatening emergencies. C. Initiate discharging stable clients for bed availability D. Stock additional unit supplies.

Correct Answer is B

Explanation

B. In a disaster situation, prioritizing care for clients with life-threatening emergencies is crucial to ensure that those in the most critical condition receive immediate attention. This aligns with triage principles and ensures that limited resources are used effectively.
A. While addressing ADLs is important, it is secondary to addressing life-threatening emergencies in a disaster scenario.
C. Discharging stable clients can help increase bed availability but should be considered after addressing immediate life-threatening needs.
D. Stocking additional supplies is necessary but should follow after ensuring that life-threatening conditions are managed.

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["33"]

Explanation

A nurse is working with a limited staff because of a severe storm in the area. The facility incident commander has initiated disaster protocols. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

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