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 B
Explanation
A. Consulting with a healthcare provider before taking over-the-counter medications is appropriate, as some medications can affect blood glucose levels or interact with diabetes medications.
B. It is crucial for clients with diabetes to continue taking insulin during illness, even if they are unable to eat. Insulin needs may increase due to stress or infection, and not taking insulin could lead to hyperglycemia or diabetic ketoacidosis. Checking blood sugar every 2 hours is correct, but insulin should not be omitted.
C. Calling the doctor if the illness lasts longer than 2 days is a good practice, as prolonged illness can affect diabetes management and may require medical intervention.
D. Calling the doctor if blood sugar is over 250 mg/dL or if there is protein in the urine is appropriate, as these conditions can indicate complications that need medical attention.
Correct Answer is A
Explanation
A. The statement about keeping the temperature cold to avoid becoming overheated requires further teaching. While avoiding excessive heat is important, maintaining an overly cold environment can also trigger symptoms, such as Raynaud's phenomenon, which is common in SLE patients. Proper temperature regulation, rather than extremes, is essential.
B. Following the prescribed medication regimen and informing the healthcare provider of any side effects is crucial for managing SLE and preventing flare-ups. This demonstrates the client's understanding of the importance of medication adherence.
C. Managing stress through relaxation techniques and therapy is appropriate, as stress is known to exacerbate SLE. This statement reflects an understanding of the need to reduce stress to manage the disease effectively.
D. Wearing protective clothing when going outside is essential to prevent sun exposure, which can trigger SLE flare-ups. This indicates that the client understands the need for sun protection.
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