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 A
Explanation
Choice A rationale:
Swelling around the eyelids and mouth could indicate an allergic reaction, which can be severe in some cases. Anaphylaxis is a life-threatening reaction that can occur after immunizations. The nurse's priority is to assess and address any signs of an allergic reaction promptly. Swelling of the face, particularly around the eyes and mouth, is a red flag for potential anaphylaxis, and immediate intervention is necessary to prevent further complications.
Choice B rationale:
A temperature of 100.7 degrees Fahrenheit is considered a mild fever. While it's important to monitor for fever after immunizations, a mild fever alone may not be the nurse's top priority, especially if the child is otherwise stable. Fever can be a common post-immunization response and is often self-limiting.
Choice C rationale:
While monitoring the child's intake is important, only eating 2 ounces during the last feeding is not a priority concern compared to potential allergic reactions or fever. A temporary decrease in appetite following immunizations can be expected and might resolve on its own.
Choice D rationale:
Crying when the injection site is touched is a common response to discomfort from the shot. While it's essential to provide comfort and support to the child, this finding is not indicative of a severe reaction. It's not the nurse's priority compared to potential signs of an allergic reaction or a more significant fever.
Correct Answer is C
Explanation
Choice A rationale:
Cleaning the infant's suture line with chlorhexidine solution is not indicated immediately after cleft lip repair. The primary concern in the immediate postoperative period is pain management and wound healing, and cleaning the suture line with chlorhexidine could potentially disrupt the healing process.
Choice B rationale:
Applying elbow immobilizers to the infant is not necessary after cleft lip repair. Elbow immobilizers are typically used in situations where there's a need to restrict arm movement, such as preventing a child from bending their arms after certain types of surgery. Cleft lip repair does not involve the arms, so this action is not relevant.
Choice C rationale:
Correct Choice. Offering the infant a pacifier with sucrose for pain relief is appropriate. Non-nutritive sucking, such as using a pacifier, has been shown to have pain-relieving effects in infants. Sucrose, a sweet solution, is often used in combination with non-nutritive sucking to further enhance pain relief during minor procedures or painful experiences. It provides comfort and distraction to the infant, helping to reduce their discomfort.
Choice D rationale:
Placing the infant in a prone position for sleeping is contraindicated after cleft lip repair. Placing an infant prone (on their stomach) for sleep increases the risk of sudden infant death syndrome (SIDS). The recommended sleep position for infants is supine (on their back) to ensure their safety.
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