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. Absence of pulmonary and peripheral edema is not a primary goal of vasopressor therapy. The focus is on improving blood pressure and perfusion.
B. Vasopressor therapy aims to increase blood pressure, not reduce stroke volume or cardiac output.
C. Vasopressors are used to increase blood pressure, so reducing blood pressure is not an intended goal.
D. The primary goal of vasopressor therapy in septic shock is to maintain an adequate mean arterial pressure (MAP) to ensure adequate organ perfusion and prevent organ failure.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}
Explanation
Intravenous fluid administration is anticipated as hydration can help reduce the viscosity of sickled cells, improving circulation and potentially reducing vaso-occlusive events.
Ice packs to the affected area are nonessential and could potentially be contraindicated, as cold can cause vasoconstriction and may exacerbate pain.
Ambulation is nonessential during acute pain episodes and should be encouraged when the patient is comfortable and pain is controlled.
Hydromorphone IV for pain is anticipated because it is a stronger opioid than morphine and may be necessary if the pain is unresponsive to oral morphine sulfate.
Acetaminophen PO for pain is nonessential in this scenario as it is unlikely to provide adequate pain relief for severe vaso-occlusive pain.
Oxygen therapy is nonessential given the client's SpO2 is 95% on room air, indicating adequate oxygen saturation; however, it may be considered if there is evidence of hypoxia or respiratory distress. It is crucial to monitor the client's response to pain management interventions and adjust the treatment plan accordingly.
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