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Exhibits

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16-year-old adolescent brought to the ED for a sudden onset of fever. headache, and reports of sensitivity to light. Guardian reports adolescent refuses to eat or drink due to nausea and vomiting.

Adolescent is lethargic and drowsy but arouses with verbal stimuli. Irritable when aroused. Pupils equal, round, reactive to light, accommodation (PERRLA). Hand grasps and pedal pulls and pushes are strong and equal bilaterally. Mucous membranes are dry and pink. Skin is very warm and dry to touch. Capillary refill is 2 seconds. Photophobia is present. Adolescent reports headache as a 10 on a numeric pain scale of 0 to 10. Resists flexion of the neck. Has small pinpoint purpuric rash bilaterally on lower extremities.

16-year-old adolescent brought to the ED for a sudden onset of fever. headache, and reports of sensitivity to light

Guardian reports adolescent refuses to eat or drink due to nausea and vomiting

Adolescent is lethargic and drowsy but arouses with verbal stimuli

Irritable when aroused

Pupils equal, round, reactive to light, accommodation (PERRLA)

Hand grasps and pedal pulls and pushes are strong and equal bilaterally

Mucous membranes are dry and pink. Skin is very warm and dry to touch

Photophobia is present. Adolescent reports headache as a 10 on a numeric pain scale of 0 to 10

Resists flexion of the neck. Has small pinpoint purpuric rash bilaterally on lower extremities

Capillary refill is 2 seconds

Answer and Explanation

The Correct Answer is ["A","B","C","D","H","I"]

Rationale:

Sudden onset of fever, headache, sensitivity to light (photophobia): This triad of symptoms is a hallmark of meningeal irritation and strongly suggests meningitis. The sudden onset of fever and headache, paired with photophobia (light sensitivity), is often seen in bacterial or viral meningitis.
Lethargic and drowsy but arouses with verbal stimuli, Irritable when aroused: This indicates an altered mental status, which is concerning in the context of suspected meningitis. Altered consciousness (such as lethargy and irritability when aroused) suggests central nervous system (CNS) involvement, often due to an infection like meningitis.
Headache as a 10 on a numeric pain scale of 0 to 10: A severe headache is a key symptom of meningeal irritation, often caused by the inflammation of the meninges in conditions like meningitis. The intensity of the headache (10 out of 10) warrants immediate attention and pain management, alongside investigating the underlying cause.
Resists flexion of the neck (Nuchal rigidity): Nuchal rigidity (neck stiffness) is a cardinal sign of meningitis or meningeal irritation. It indicates inflammation of the meninges. This finding, especially when combined with other symptoms, strongly points toward meningitis.
Small pinpoint purpuric rash bilaterally on lower extremities: A purpuric rash (non-blanching could indicate meningococcemia, a severe form of bacterial meningitis caused by Neisseria meningitidis. The presence of this rash requires immediate attention and intervention.

Rationale for incorrect Findings:

Pupils equal, round, reactive to light, accommodation (PERRLA); This finding suggests that the infant's neurological status is stable in terms of pupil response, with no immediate signs of increased intracranial pressure or brain herniation.
Hand grasps and pedal pulls and pushes are strong and equal bilaterally: This indicates that the infant is still demonstrating full motor strength and function in the limbs, which is reassuring in the context of meningeal irritation. There is no immediate evidence of weakness or paralysis.

Mucous membranes are pink and dry: Pinl mucous membranes suggest adequate perfusion and dry mucous membranes could indicate dehydration, which is common with fever and poor oral intake. While it is a concern, the dryness of mucous membranes does not directly point to a critical or life-threatening issue like the neurological findings.
Skin is very warm and dry to touch: The warmth and dryness of the skin indicate fever, which is expected in infections such as meningitis. Fever management, such as antipyretics (e.g., acetaminophen), is necessary, but it is not as urgent as other neurological findings.
Capillary refill is 2 seconds: A capillary refill time of 2 seconds is considered normal. It suggests that the child has adequate perfusion and circulation. This is a reassuring sign and does not require immediate follow-up.

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Gently cleanse the surgical site with sterile gauze: direct vigorous cleansing of the palate surgical site with gauze is generally avoided to prevent disruption of sutures. Oral rinses or specific gentle cleaning methods may be prescribed, but direct gauze wiping is usually not recommended.
B. Offer a pacifier with glucose syrup: acifiers and any sucking on objects (including straws, spoons, or toys) are typically contraindicated after cleft palate repair because the sucking motion puts stress on the suture line and can disrupt healing.
C. Apply elbow immobilizers to both arms: Elbow immobilizers prevent the infant from bending their elbows and bringing their hands to their mouth or face, which could disrupt the surgical sutures, cause trauma, or introduce infection to the delicate palate repair.
D. Place the infant in a supine position: A semi-upright position is usually preferred to reduce pressure on the surgical site and prevent aspiration, rather than placing the infant flat on their back.

A. Insert a peripheral IV catheter. B. Place the adolescent on a cooling blanket. C. Administer IV acyclovir. D. Place on seizure precautions. E. Keep adolescent flat in bed for 24 hr post lumbar puncture. F. Administer IV cefotaxime.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

Rationale:

Insert a peripheral IV catheter: A peripheral IV catheter is essential for administering fluids and medications, which is critical for this adolescent, especially with the concern for bacterial meningitis.
Place the adolescent on a cooling blanket: The adolescent has a high fever (39°C), which needs to be managed promptly to prevent further complications. A cooling blanket helps reduce the fever and manage the patient’s temperature.
Administer IV acyclovir: Acyclovir is an antiviral medication typically used to treat viral infections such as herpes simplex virus or varicella-zoster virus, not bacterial meningitis. Given the CSF findings and suspected bacterial meningitis, acyclovir is not appropriate. Antibiotics like cefotaxime are indicated instead.
Place on seizure precautions: Given the adolescent's symptoms (e.g., headache, photophobia, lethargy), the risk of seizures is elevated, especially if meningitis is suspected. Seizure precautions are important to prevent injury during a potential seizure.
Keep adolescent flat in bed for 24 hr post lumbar puncture: After a lumbar puncture, keeping the adolescent flat in bed for 24 hours helps prevent post-lumbar puncture headaches and minimizes the risk of cerebrospinal fluid leaks or complications.
Administer IV cefotaxime: IV cefotaxime is an appropriate antibiotic for treating bacterial meningitis. Given the abnormal CSF results (low glucose, high protein, elevated WBC), the adolescent is at high risk for bacterial meningitis, and IV cefotaxime is expected to be part of the treatment plan.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an infant who is postoperative following repair of a cleft palate. Which of the following is an appropriate action by the nurse?

Correct Answer is C

Explanation

Exhibits For each potential provider prescription, click to specify if the prescription is expected or unexpected for the adolescent. There must be at least 1 selection in every row. There does not need to be a selection in every column.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

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