A nurse is caring for a client on the medical-surgical floor.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the

client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

The potential condition the client is most likely experiencing is a Hemorrhagic Stroke.

Prepare the client for a STAT CT brain: The client presents with sudden onset of severe headache described as the worst of their life, along with additional neurological symptoms such as left-sided weakness, aphasia, photophobia, and loss of peripheral vision. These symptoms are highly concerning for a possible hemorrhagic stroke, which requires urgent imaging such as a CT scan of the brain to confirm the diagnosis and guide immediate treatment.
Place the client on seizure precautions: The client has reported left-sided weakness and aphasia, indicating neurological deficits. Additionally, they have a history of atrial fibrillation and are on anticoagulant therapy with warfarin, resulting in an elevated INR of 4.9. This INR level suggests a significantly increased risk of bleeding, including intracranial bleeding. Given these factors, the client is at risk of experiencing seizures, which is a potential complication of hemorrhagic stroke. Placing the client on seizure precautions involves ensuring their safety and preventing injury in the event of a seizure.

Parameters to Monitor:

Temperature: Monitoring temperature is important to assess for the presence of fever, which could indicate an infectious process such as meningitis. However, in this case, the client's fever is likely related to their urinary tract infection rather than directly related to the stroke. Nonetheless, monitoring temperature is still essential for overall assessment and management.
PT/INR: Monitoring the PT/INR is crucial due to the client's history of atrial fibrillation and anticoagulant therapy with warfarin. The elevated INR of 4.9 suggests that the client is at increased risk of bleeding, including intracranial bleeding. Close monitoring of PT/INR levels will help guide adjustments to anticoagulant therapy and assess the risk of further bleeding complications.

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Correct Answer is []

Explanation

The client is most likely experiencing meningitis based on the following clinical manifestations:

Symptoms: The client presents with a 2-day history of lethargy, nausea, vomiting, anorexia, headache, general muscle aches, diarrhea, abdominal pain, sore throat, sensitivity to light, and intermittent nystagmus. These symptoms are consistent with the classic signs of meningitis, including headache, nausea, vomiting, photophobia, and altered mental status.
Physical Examination Findings: The physical examination reveals a fever (temperature of 38.9°C or 102°F), elevated heart rate (118/min), and signs of meningeal irritation such as neck stiffness (not directly mentioned but implied by headache and sensitivity to light). Additionally, a pinpoint, red, macular rash on the upper chest may indicate petechiae, which can be seen in meningococcal meningitis.

Given the suspicion of meningitis, the nurse should take the following actions:

Implement seizure precautions: Meningitis can lead to increased intracranial pressure and neurological complications, including seizures. Implementing seizure precautions involves ensuring the client's safety by padding the side rails of the bed, keeping the bed in a low position, and providing close observation.
Dim the lights in the client’s room: The client reports sensitivity to light, which is a common symptom of meningitis due to meningeal irritation. Dimming the lights can help reduce discomfort and photophobia in the client.

Parameters to Monitor:

Neurologic status: Monitoring the client's neurologic status is crucial for assessing the progression of meningitis and detecting any neurological deterioration, such as changes in level of consciousness, motor deficits, or signs of increased intracranial pressure.
Temperature: Monitoring the client's temperature is essential to assess for fever spikes or trends, which can indicate the severity of the infection and response to treatment.

Persistent or worsening fever may suggest inadequate treatment or complications such as abscess formation.

A. Intracranial pressure B. Respiratory status C. Temperature D. Serum electrolytes

Correct Answer is B

Explanation

A. Intracranial pressure: Monitoring intracranial pressure is important in clients with a history of subdural hematoma, but immediate assessment of respiratory status takes precedence in the immediate postoperative period to ensure adequate oxygenation and ventilation.

B. Respiratory status: Following evacuation of a subdural hematoma, the client may be at risk for respiratory compromise due to factors such as altered consciousness, impaired airway reflexes, or postoperative complications. Assessing respiratory rate, depth, oxygen saturation, and presence of respiratory distress is essential for early detection and intervention.

C. Temperature: Monitoring temperature is important for detecting signs of infection or systemic complications, but it is not the priority assessment immediately following evacuation of a subdural hematoma.

D. Serum electrolytes: While monitoring serum electrolytes is important for overall assessment and management of the client's condition, it is not the priority assessment in the immediate postoperative period following evacuation of a subdural hematoma.

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Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

A nurse is caring for a client 4 hours following evacuation of a subdural hematoma. Which of the following assessments is the nurse's priority?

Correct Answer is B

Explanation

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