A nurse is caring for a 30-year-old client who was brought to the emergency department (ED).
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Neurogenic shock is characterized by the loss of sympathetic tone, leading to parasympathetic predominance. Therefore, signs of sympathetic stimulation, such as tachycardia or sweating, are not present.
B. Neurogenic shock typically causes hypotension, not hypertension, due to vasodilation and decreased systemic vascular resistance.
C. Cool, moist skin is more commonly seen in hypovolemic or septic shock due to peripheral vasoconstriction. In neurogenic shock, vasodilation leads to warm, dry skin.
D. Bradycardia is a hallmark of neurogenic shock due to unopposed parasympathetic stimulation resulting from the loss of sympathetic nervous system control.
Correct Answer is A
Explanation
A. A client with extreme muscle weakness on the affected side should use a cane or other assistive devices to aid in mobility and ensure safety. This intervention helps the client maintain stability and prevent falls.
B. The client with muscle weakness should use the unaffected hand for daily activities to ensure safety and improve functional outcomes. Using the affected hand may increase the risk of injury.
C. A soft diet and thickened liquids are generally recommended for clients with dysphagia, which is not specifically indicated in the context of muscle weakness due to a stroke.
D. Encouraging the client to complete all ADLs independently may not be feasible or safe due to the muscle weakness. Support and assistance with ADLs are likely needed.
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