A nurse is collecting data from a client who has encephalitis due to West Nile virus. Which of the following findings should the nurse expect? (Select all that apply.)
Unilateral weakness
Stiff neck
Photophobia
Epigastric pain
Lethargy
Correct Answer : B,C,E
Choice A reason: Unilateral weakness is an incorrect finding, because it is more indicative of a stroke or a brain tumor than encephalitis. Encephalitis is an inflammation of the brain that can cause neurological symptoms, but they are usually bilateral and symmetrical.
Choice B reason: Stiff neck is a correct finding, because it is a sign of meningeal irritation, which can occur in encephalitis due to the involvement of the meninges (the membranes that cover the brain and spinal cord).
Choice C reason: Photophobia is a correct finding, because it is another sign of meningeal irritation, which can cause sensitivity to light and sound.
Choice D reason: Epigastric pain is an incorrect finding, because it is not related to encephalitis. Epigastric pain is more likely to be caused by a gastrointestinal disorder, such as gastritis or peptic ulcer.
Choice E reason: Lethargy is a correct finding, because it is a sign of altered mental status, which can occur in encephalitis due to the damage to the brain tissue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is an important data, but not the first one. The nurse should first assess the client's airway, breathing, and circulation, which are the priorities in any emergency situation.
Choice B reason: This is the correct data, because the nurse should first collect the respiratory rate to determine if the client has any signs of airway obstruction, inhalation injury, or respiratory distress, which are life-threatening complications of facial burns.
Choice C reason: This is a relevant data, but not the first one. The nurse should collect the presence of bowel sounds later, after ensuring the client's airway, breathing, and circulation are stable, to assess the client's gastrointestinal function and possible paralytic ileus.
Choice D reason: This is a significant data, but not the first one. The nurse should collect the level of pain later, after ensuring the client's airway, breathing, and circulation are stable, to provide adequate analgesia and comfort measures.
Correct Answer is B
Explanation
Choice A reason: This is an incorrect statement, because the client should avoid any body piercings, tattoos, or other procedures that can cause skin or mucosal trauma and increase the risk of bacterial infection and endocarditis. The client should also seek medical attention if they have a fever or other signs of infection.
Choice B reason: This is a correct statement, because the client should notify their doctor before they have dental procedures, such as cleaning, filling, or extraction, that can cause bleeding and introduce bacteria into the bloodstream. The client may need prophylactic antibiotics to prevent endocarditis.
Choice C reason: This is a partially correct statement, because the client should floss their teeth twice a day as a part of their oral care, but this is not enough to prevent recurrence of endocarditis. The client should also brush their teeth with a soft toothbrush after each meal, use an antiseptic mouthwash, and visit their dentist regularly.
Choice D reason: This is an unnecessary statement, because the client does not need to wear a mask when they go out in public, unless they have a respiratory infection or are exposed to someone who has one. Endocarditis is not transmitted by airborne or droplet routes, but by direct contact with the infected heart valves or blood.
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