Exhibits

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

The client is at risk for developing

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as evidenced by

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.

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.

A. Administer magnesium sulfate IM to the child: Seizures are typically managed with anticonvulsant medications or other specific treatments, but magnesium sulfate is primarily used in other conditions, such as preeclampsia in pregnant women.
B. Place a folded blanket under the child's head: Placing a folded blanket or soft material under the child's head is a safe action to prevent injury during a tonic-clonic seizure. It helps protect the head from hitting the floor or any hard surfaces during the seizure.
C. Prevent movement of the child's extremities: It is not recommended to try to prevent movement of the child's extremities during a tonic-clonic seizure. Trying to restrain or hold the child down can cause injury. The goal is to ensure the child’s safety and prevent injury.
D. Put a tongue blade between the child's teeth: Inserting a tongue blade between the child’s teeth is dangerous and should never be done. It could lead to injury, including broken teeth or damage to the child's mouth or throat.