A nurse is collecting data from a school-age child who has bacterial meningitis. Which of the following findings should the nurse expect? (Select all that apply.)
Headache.
Negative Kernig sign.
Vomiting.
Seizures.
Tinnitus.
Correct Answer : A,B,C,D
Choice A rationale:
Headache is an expected finding in a school-age child with bacterial meningitis. Bacterial meningitis is an inflammation of the meninges, and the membranes surrounding the brain and spinal cord, often caused by bacteria. The inflammatory process can lead to increased intracranial pressure, which commonly presents as a headache. This headache is often severe and can be accompanied by other symptoms like fever, irritability, and sensitivity to light.
Choice B rationale:
A negative Kernig sign is a possible finding in a school-age child with bacterial meningitis. Kernig sign is a clinical test performed to assess for meningitis. A positive Kernig sign is characterized by resistance and pain in extending the knee when the hip is flexed at a 90-degree angle. However, a negative Kernig sign does not rule out meningitis, as it might not always be present.
Choice C rationale:
Vomiting is an expected finding in a school-age child with bacterial meningitis. The increase in intracranial pressure due to inflammation of the meninges can lead to nausea and vomiting. The vomiting is often projectile and may not be relieved by eating or drinking.
Choice D rationale:
Seizures are an expected finding in a school-age child with bacterial meningitis. The inflammation of the brain and meninges can irritate the brain tissue and trigger seizures. Seizures in the context of bacterial meningitis might be generalized or focal in nature.
Choice E rationale:
Tinnitus (ringing in the ears) is not a typical finding associated with bacterial meningitis. The main symptoms of bacterial meningitis are related to the central nervous system and meningeal irritation, such as headache, fever, neck stiffness, and neurological changes. Tinnitus is not a common manifestation of bacterial meningitis and is not part of the typical clinical picture.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Contact precautions are indicated when the client has a condition that can be easily transmitted through direct contact with the client or their environment. Measles, which is an airborne disease, requires more stringent precautions due to its mode of transmission.
Choice B rationale:
The correct choice. Measles is spread through airborne particles, making airborne precautions necessary. These precautions include placing the client in a negative pressure room, wearing appropriate respiratory protection (e.g., N95 mask), and ensuring that healthcare providers are properly protected from inhaling infectious particles.
Choice C rationale:
A protective environment is a specialized form of isolation used for clients with compromised immune systems, such as those undergoing stem cell transplants. It involves maintaining a sterile environment to prevent the introduction of pathogens. This level of precautions is not applicable to clients with measles.
Choice D rationale:
Droplet precautions are appropriate for diseases that are transmitted through respiratory droplets generated by coughing, sneezing, or talking. Measles, however, is transmitted through smaller airborne particles that can remain suspended in the air for longer periods, making airborne precautions the most suitable choice.
Correct Answer is C
Explanation
Choice A rationale:
Placing a toddler in a side-lying position on the affected side after administering otic medication is not recommended. This position can cause the medication to leak out, reducing its effectiveness, and can also increase the risk of infection. It's important to keep the medication in the ear canal for an adequate amount of time to allow it to work properly.
Choice B rationale:
Allowing the medication to reach room temperature prior to administration is not a critical step for otic medications. While warming certain medications can reduce discomfort, this is not a specific requirement for ear drops. Ensuring the cleanliness of the ear, proper positioning, and correct administration technique are more important.
Choice C rationale:
The correct choice. Sitting the child in an upright position is the recommended approach for administering otic medication. This position helps ensure that the medication remains in the ear canal and is not immediately expelled. It also facilitates better penetration of the medication into the ear canal, increasing its effectiveness.
Choice D rationale:
Gently pulling a child's ear upward is a technique used for administering otic medications to straighten the ear canal and allow better access to the medication. However, this step alone is not sufficient. Proper positioning of the child is equally important to prevent the medication from leaking out.
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