A client is admitted with bacterial meningitis. Which nursing intervention is the highest priority for this client?
Strict monitoring of hourly intake and output
Managing pain through drug and non-drug methods
Assessing neurological status at least every 2 to 4 hours
Decreasing environmental stimuli
The Correct Answer is C
Choice A reason:
Strict monitoring of hourly intake and output is important for managing fluid balance and detecting potential complications such as dehydration or fluid overload1. However, it is not the highest priority in the acute phase of bacterial meningitis. The primary concern is to monitor for signs of increased intracranial pressure (ICP) and neurological deterioration.
Choice B reason:
Managing pain through drug and non-drug methods is essential for patient comfort and overall well-being. Pain management can help reduce stress and improve the patient’s ability to rest and recover. However, it is not the highest priority compared to monitoring neurological status, which can provide early indications of complications such as increased ICP or seizures.
Choice C reason:
Assessing neurological status at least every 2 to 4 hours is the highest priority for a client with bacterial meningitis. This frequent assessment helps detect early signs of neurological deterioration, increased ICP, and other complications. Early detection and intervention are crucial in preventing severe outcomes and improving the patient’s prognosis.
Choice D reason:
Decreasing environmental stimuli is important to reduce stress and prevent exacerbation of symptoms such as headache and photophobia. While this intervention is beneficial, it is not as critical as frequent neurological assessments in the acute management of bacterial meningitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A reason: Pink frothy sputum is a classic sign of pulmonary edema, which can occur as a result of oxygen toxicity. When the alveoli in the lungs fill with fluid, it can lead to this type of sputum. This is a critical indicator that the client is experiencing severe respiratory distress and requires immediate medical attention.
Choice B reason: Substernal discomfort or chest pain is another symptom of oxygen toxicity. This discomfort arises due to the irritation and inflammation of the lung tissues caused by high levels of oxygen. It is essential to monitor and address this symptom promptly to prevent further complications.
Choice C reason: Nail clubbing is typically associated with chronic hypoxia and long-term lung diseases, but it is not an acute indicator of oxygen toxicity. Therefore, it is not relevant in this context.
Choice D reason: Restlessness is a common early sign of hypoxia and can also indicate oxygen toxicity. When the brain does not receive adequate oxygen, it can lead to symptoms such as restlessness, confusion, and agitation. This symptom should be taken seriously and addressed immediately.
Choice E reason: Cyanosis at the nail beds indicates a lack of oxygen in the blood, but it is not specific to oxygen toxicity. It can occur in various conditions where there is inadequate oxygenation, such as chronic obstructive pulmonary disease (COPD) or heart failure.
Correct Answer is ["E","F","G"]
Explanation
Choice A reason:
Hypertension is not typically associated with myxedema coma. Myxedema coma is characterized by severe hypothyroidism, which usually leads to low blood pressure (hypotension) rather than high blood pressure (hypertension). Therefore, hypertension is not a clinical manifestation that indicates progression to myxedema coma.
Choice B reason:
Restlessness is not a common symptom of myxedema coma. Patients with myxedema coma often present with lethargy, confusion, or even coma due to the severe slowing of metabolic processes. Restlessness is more commonly associated with hyperthyroidism or other conditions that increase metabolic activity.
Choice C reason:
An increased level of alertness is contrary to the symptoms of myxedema coma. Myxedema coma typically presents with decreased mental status, including confusion, stupor, or coma. Therefore, an increased level of alertness would not be indicative of progression to myxedema coma.
Choice D reason:
Tachycardia (rapid heart rate) is not a typical symptom of myxedema coma. Instead, myxedema coma is associated with bradycardia (slow heart rate) due to the severe hypothyroid state. Tachycardia is more commonly seen in hyperthyroid conditions.
Choice E reason:
Hypotension (low blood pressure) is a key clinical manifestation of myxedema coma. The severe hypothyroid state leads to decreased cardiac output and vascular resistance, resulting in hypotension. This is a critical sign that the nurse should recognize as indicative of progression to myxedema coma.
Choice F reason:
Bradycardia (slow heart rate) is another hallmark of myxedema coma. The decreased metabolic rate in severe hypothyroidism leads to a reduced heart rate. Recognizing bradycardia is essential in identifying the progression to myxedema coma.
Choice G reason:
Hypoventilation (reduced breathing rate) is a significant symptom of myxedema coma. The severe hypothyroid state can lead to respiratory depression, resulting in hypoventilation. This can further exacerbate the patient’s condition and requires immediate medical attention.
Choice H reason:
Hyperventilation (increased breathing rate) is not associated with myxedema coma. Patients with myxedema coma typically experience hypoventilation due to the severe slowing of metabolic processes. Hyperventilation would be more indicative of conditions that increase metabolic activity or respiratory drive.
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