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A nurse is caring for a client who has just been admitted to the emergency department (ED).

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 []

Potential Condition

Meningitis: The client's symptoms of severe headache, fever, photophobia, nuchal rigidity, and lethargy are characteristic of meningitis. The presence of these signs suggests inflammation of the protective membranes surrounding the brain and spinal cord. Immediate evaluation and treatment are essential due to the potential severity of this condition.
Septic shock: While the client presents with fever and tachycardia, the vital signs and symptoms do not strongly indicate septic shock, which typically involves more profound hypotension, altered mental status, and signs of organ dysfunction. The client’s blood pressure remains relatively stable despite other symptoms.
Migraine headache: Although the client reports a severe headache, the additional symptoms of fever, photophobia, and nuchal rigidity suggest an infectious process rather than a primary headache disorder. Migraines do not usually present with systemic signs such as fever and muscle rigidity.
Hydrocephalus: Hydrocephalus typically presents with increased intracranial pressure, characterized by symptoms such as headache, nausea, vomiting, and altered mental status. The client’s primary complaint is a headache and neck stiffness, but there are no indications of increased intracranial pressure or the classic triad of symptoms seen in hydrocephalus.

Actions to Take:

Initiate neurological checks every 2 hr: Frequent neurological assessments are crucial for monitoring changes in mental status, level of consciousness, and other signs of increased intracranial pressure or neurological deterioration. This helps ensure timely interventions if the client's condition worsens.
Decrease environmental stimuli: Reducing noise and light in the environment can help minimize discomfort and agitation for the client with meningitis, particularly given their symptoms of photophobia and malaise. A calm and quiet environment promotes comfort and supports recovery.
Prepare the client for surgery: While surgery may be necessary in some cases of meningitis, it is not an immediate action to take without further evaluation or evidence of complications such as an abscess. The primary focus should be on monitoring and supportive care initially.
Administer gabapentin: Gabapentin is typically used for neuropathic pain or seizures, not as a primary treatment for meningitis. The immediate treatment for meningitis involves antibiotics and supportive care rather than gabapentin.

Parameters to Monitor:

Temperature: Monitoring temperature is vital in clients with meningitis to assess for ongoing infection and evaluate the effectiveness of antipyretic interventions. Fever management is important in reducing metabolic demand and preventing further complications.
Lactate level: Elevated lactate levels can indicate tissue hypoperfusion and may signify the severity of infection or sepsis. Monitoring lactate helps assess the client's overall condition and response to treatment, guiding further interventions as needed.
Bowel sounds: Monitoring bowel sounds is not a priority in the context of meningitis and does not provide relevant information about the client's neurological status or condition.
Vascular changes: While assessing vascular changes can be important in some critical conditions, it is not directly related to the management of meningitis. The focus should be on neurological and systemic assessments.
Gait: Gait assessment may be relevant for neurological conditions but is not applicable in this acute setting where the client is presenting with signs of meningitis. The priority is to monitor neurological status and vital signs rather than gait at this time.

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Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}

Explanation

Myocardial infarction: The rising troponin levels (Troponin T increasing from 0.08 ng/mL to 0.2 ng/mL and Troponin I rising from 0.01 ng/mL to 0.1 ng/mL) indicate myocardial injury. Persistent chest tightness, shortness of breath, diaphoresis, and anxiety suggest ongoing ischemia. The lack of complete pain relief after nitroglycerin further supports myocardial infarction rather than stable angina.
Pulmonary embolism: Shortness of breath is a symptom of pulmonary embolism, but the absence of acute hypoxia, pleuritic chest pain, or significant coagulation abnormalities makes this less likely. The client's symptoms and laboratory findings more strongly support a cardiac etiology.
Bleeding: While thrombolytic therapy increases bleeding risk, the aPTT (32 seconds) and platelet count (350,000/mm³) are within normal limits. There are no reported signs of active bleeding, such as hypotension, bruising, or hematuria, making this a less relevant immediate concern.
Shortness of breath: Often present in myocardial infarction due to decreased cardiac output and pulmonary congestion. The combination of chest pain, diaphoresis, and dyspnea suggests worsening ischemia rather than a primary pulmonary process. However, it is a nonspecific symptom that can also indicate pulmonary embolism or respiratory distress.
aPTT levels: Normal at 32 seconds (reference: 30–40 seconds), which suggests no immediate risk of abnormal clotting or excessive anticoagulation. This finding does not directly indicate myocardial infarction but is important in monitoring bleeding risk with thrombolytic therapy. A significantly elevated aPTT could raise concern for hemorrhagic complications.
Elevated troponin levels: A highly specific marker for myocardial injury. The rise in Troponin T and Troponin I over time confirms myocardial damage, distinguishing acute coronary syndrome from stable angina. This trend is critical in diagnosing myocardial infarction, as troponin elevation correlates with the extent of cardiac muscle injury.

A. PO oxycodone B. Ibuprofen via NG tube C. IV hydromorphone D. Topical lidocaine patch

Correct Answer is C

Explanation

A. PO oxycodone: Oral medications are contraindicated in clients with paralytic ileus because of impaired gastrointestinal motility, which prevents proper absorption and increases the risk of gastric retention. IV administration is preferred for effective pain control in this scenario.

B. Ibuprofen via NG tube: NSAIDs can cause gastric irritation and increase the risk of gastrointestinal bleeding, especially in clients with pancreatitis. Additionally, an NG tube is not an appropriate route for medication administration in the presence of an ileus due to impaired intestinal function.

C. IV hydromorphone: IV opioids provide effective and rapid pain relief for clients with severe pain, especially when oral or enteral administration is not feasible. Hydromorphone is commonly used in acute pancreatitis because it controls pain effectively without exacerbating the underlying condition.

D. Topical lidocaine patch: While lidocaine patches provide localized pain relief, they are not sufficient for managing severe visceral pain associated with pancreatitis and ileus. Systemic analgesia via IV opioids is more appropriate for controlling this level of pain.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has angina. Complete the following sentence by using the lists of options. The client is at risk for developing ....... due to .......

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}

Explanation

A nurse is caring for a client who has developed a paralytic ileus related to acute pancreatitis and reports pain as 8 on a scale of 0 to 10. The client has prescriptions for multiple PRN pain medications. Which of the following medications should the nurse administer?

Correct Answer is C

Explanation

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