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Exhibits

Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

The client is at risk for developing

as evidenced by.
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}

Rationale for Correct Choices:

  • Seizures: The adolescent’s fever, headache, photophobia, and neck stiffness (resistance to flexion) are consistent with signs of meningitis, which can lead to seizures, especially in the setting of increased intracranial pressure. Seizures are a known complication of untreated or severe meningitis.
  • Signs of meningeal irritation: The adolescent demonstrates classic signs of meningeal irritation, such as photophobia, severe headache, and neck stiffness, which suggest inflammation of the meninges. This is a key indicator of potential meningitis and the associated risk of seizures.

Rationale for Incorrect Choices:

  • Lyme disease: While Lyme disease can cause neurological symptoms, including headache and fever, the absence of a characteristic erythema migrans rash or recent tick exposure makes it less likely.
  • Constipation: Constipation is not a likely complication given the adolescent's current symptoms, which are focused on fever, headache, and neurological signs. It does not explain the risk for seizures.
  • Mononucleosis: Although mononucleosis can cause fever and malaise, it typically does not present with neck stiffness, photophobia, or the acute onset of severe headache that is suggestive of meningitis. The symptoms in this case are more concerning for meningitis.
  • Pneumonia: Pneumonia is unlikely given the absence of respiratory findings such as cough or difficulty breathing. The symptoms are more consistent with a central nervous system infection, like meningitis, than a respiratory infection.
  • Fever: While fever is present in meningitis, it alone does not indicate the risk for seizures. It is the combination of fever, headache, photophobia, and meningeal signs that increases the risk for complications like seizures.
  • Inability to eat and drink: The inability to eat and drink is likely a result of nausea and vomiting, which is common in many illnesses, including meningitis. However, it is not a direct indicator of the risk for seizures, which is more strongly linked to meningeal irritation.
  • Respiratory findings: There are no significant respiratory symptoms, such as difficulty breathing or abnormal lung sounds, making respiratory findings irrelevant in this case. The adolescent’s symptoms are primarily neurological.


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Related Questions

Correct Answer is B

Explanation

A. This area is over the cheek and facial soft tissue. Cephalohematomas do not occur here, as they are confined to the skull bones under the periosteum.

B. This point is positioned over the parietal area of the skull, the typical site for cephalohematoma formation due to birth trauma. Cephalohematoma is a subperiosteal hemorrhage confined to the surface of the skull, most commonly over the parietal bone, and does not cross suture lines. Palpating this area helps determine whether the lesion has resolved or calcified.

C. This region is the lower abdominal or pelvic area, which is not relevant for assessing cranial birth trauma like cephalohematoma.

Correct Answer is ["C","D"]

Explanation

A. "There is nothing we can do to minimize overgrowth of their gum tissue.": Incorrect. Gingival hyperplasia is a known side effect of phenytoin, but good oral hygiene and regular dental care can help minimize its severity.
B. "They will need to take 400 IU of vitamin E while on this medication.": Incorrect. Routine vitamin E supplementation is not standard or necessary with phenytoin unless specifically indicated by a provider.
C. "We will need to periodically have their blood drawn to check phenytoin levels.": Correct. Phenytoin has a narrow therapeutic index, so serum drug levels must be monitored regularly to avoid toxicity or subtherapeutic dosing.
D. "This medication may cause their eyes to, at times, move quickly back and forth.": Correct. Nystagmus is a known dose-related side effect of phenytoin, especially at higher levels.
E. "This drug won't decrease the effectiveness of their oral contraceptive medication.": Incorrect. Phenytoin is a hepatic enzyme inducer and can reduce the effectiveness of hormonal contraceptives, so alternate or additional contraceptive methods should be recommended.

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