A nurse is caring for an adolescent who was brought to the emergency department (ED) with a fever, headache, and neck stiffness. The nurse should determine the assessment findings are consistent with which of the following disease processes?
Bacterial meningitis
Encephalitis
Gastroenteritis
Migraine
The Correct Answer is A
Choice A reason: Bacterial meningitis is an inflammation of the meninges, the membranes that cover the brain and spinal cord, caused by a bacterial infection. It can cause fever, headache, neck stiffness, photophobia, and altered mental status. The cerebrospinal fluid (CSF) analysis may show increased white blood cells, protein, and glucose. The nurse should assess the neck range of motion and the reaction to pupil assessment, as these may indicate increased intracranial pressure.
Choice B reason: Encephalitis is an inflammation of the brain tissue, usually caused by a viral infection. It can cause fever, headache, confusion, seizures, and focal neurological deficits. The CSF analysis may show increased white blood cells and protein, but normal glucose. The nurse should assess the level of consciousness and the neurological status, as these may indicate brain damage.
Choice C reason: Gastroenteritis is an inflammation of the stomach and intestines, usually caused by a viral or bacterial infection. It can cause nausea, vomiting, diarrhea, abdominal pain, and dehydration. The nurse should assess the gastrointestinal manifestations and the vital signs, as these may indicate fluid and electrolyte imbalance.
Choice D reason: Migraine is a type of headache that involves recurrent episodes of moderate to severe pain, usually on one side of the head, often accompanied by nausea, vomiting, and sensitivity to light and sound. The nurse should assess the location and duration of pain, the triggers and relievers, and the history of migraine. The CSF analysis is usually normal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This statement shows that the parents understand that toddlers need a balanced diet that includes a variety of foods from different food groups. The quality of food is more important than the quantity, as toddlers may have erratic eating patterns and may not consume large amounts of food at one time.
Choice B reason: This statement is incorrect, as toddlers typically have a decreased appetite compared to infants. This is due to their slower growth rate and increased interest in other activities. Parents should not force their toddlers to eat more than they want, but rather offer them healthy snacks and meals throughout the day.
Choice C reason: This statement is incorrect, as toddlers do not need vitamin supplements unless they have a specific deficiency or medical condition. Giving vitamins to a picky eater may not address the underlying causes of their food preferences, such as texture, taste, or appearance. Parents should encourage their toddlers to try new foods and avoid using food as a reward or punishment.
Choice D reason: This statement is incorrect, as toddlers do not need 3,000 calories per day. The average daily caloric intake for a toddler is about 1,000 to 1,400 calories, depending on their age, weight, and activity level. Parents should not overfeed their toddlers or give them high-calorie foods that may lead to obesity or malnutrition.
Correct Answer is B
Explanation
Choice A reason: Encouraging the child to take a 45 min nap daily is not a helpful instruction, as it may interfere with the child's normal sleep pattern and school schedule. The child may benefit from regular rest periods throughout the day, but not necessarily a long nap. ⁵
Choice B reason: Administering prednisone on an alternate day schedule is a helpful instruction, as it is a common way of prescribing corticosteroids for children with juvenile idiopathic arthritis. Corticosteroids are used to reduce inflammation and control symptoms, but they have many side effects, such as growth suppression, weight gain, and osteoporosis. Giving the medication every other day may reduce some of these side effects and improve compliance. ⁶
Choice C reason: Applying cool compresses for 20 min every hour is not a helpful instruction, as it may cause skin damage and discomfort. Cool compresses may be useful for acute inflammation, but not for chronic arthritis. Warm compresses or baths may be more soothing and beneficial for the child's joints. ⁷
Choice D reason: Allowing the child to stay at home on days when her joints are painful is not a helpful instruction, as it may lead to social isolation, academic difficulties, and reduced physical activity. The child should be encouraged to attend school and participate in activities as much as possible, with appropriate accommodations and modifications if needed. The child may also benefit from physical therapy, occupational therapy, and pain management strategies. ⁸
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