A nurse is caring for an adolescent who was brought to the emergency department (ED) with a high fever, headache, and neck stiffness. The nurse reviews the adolescent's cerebrospinal fluid (CSF) analysis results and notes the following:
- WBC count 300 cells/microliter (normal range: 0 to 10 cells/microliter)
- Protein 45 mg/dL (normal range: 15 to 45 mg/dL)
- Glucose 40 mg/dL (normal range: 50 to 75 mg/dL)
- Color Turbid (normal: clear and colorless)
The nurse should suspect that the adolescent has which of the following conditions?
Bacterial meningitis.
Viral meningitis.
Encephalitis.
Brain abscess.
The Correct Answer is A
Choice A reason: Bacterial meningitis is a probable condition, as it is an infection of the membranes that cover the brain and spinal cord, caused by various bacteria, such as Streptococcus pneumoniae, Neisseria meningitidis, or Haemophilus influenzae. The adolescent has many signs and symptoms of bacterial meningitis, such as fever, headache, and neck stiffness.
Choice B reason: Viral meningitis is not a likely condition, as it is an infection of the membranes that cover the brain and spinal cord, caused by various viruses, such as enteroviruses, herpes simplex virus, or mumps virus. The adolescent has some signs and symptoms of viral meningitis, such as fever, headache, and neck stiffness, but they are usually less severe than bacterial meningitis.
Choice C reason: Encephalitis is not a probable condition, as it is an inflammation of the brain tissue, usually caused by viral infections, such as herpes simplex virus, West Nile virus, or rabies virus. The adolescent has some signs and symptoms of encephalitis, such as fever, headache, and altered mental status, but they are usually accompanied by focal neurological deficits, such as seizures, paralysis, or cranial nerve palsies.
Choice D reason: Brain abscess is not a definite condition, as it is a collection of pus within the brain tissue, usually caused by bacterial infections that spread from other parts of the body, such as the ear, sinus, or lung. The adolescent has some signs and symptoms of brain abscess, such as fever, headache, and altered mental status, but they are usually accompanied by focal neurological deficits, such as seizures, paralysis, or cranial nerve palsies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Herpes simplex is a viral infection that causes painful blisters or ulcers in the mouth or on the lips. It does not cause a white, milky plaque that does not come off with rubbing.
Choice B reason: Dermatitis is a skin inflammation that causes redness, itching, and scaling. It does not affect the mouth or cause a white, milky plaque that does not come off with rubbing.
Choice C reason: Squamous cell carcinoma is a type of skin cancer that develops from the squamous cells that line the mouth and other parts of the body. It causes a hard, irregular, or ulcerated growth that may bleed or become infected. It does not cause a white, milky plaque that does not come off with rubbing.
Choice D reason: Candidiasis, also known as oral thrush, is a fungal infection that causes a white, milky plaque that coats the tongue, cheeks, and roof of the mouth. It can be scraped off, but may leave a red, sore, or bleeding surface. It is more common in people who have a weakened immune system, such as those who take antibiotics, immunosuppressants, or corticosteroids. It can also be triggered by smoking, dry mouth, or poor oral hygiene.
Correct Answer is B
Explanation
Choice A reason: Placing the client in a private room is not necessary for a client who has a high WBC count, unless they have other indications for isolation, such as an infectious disease. A high WBC count may indicate inflammation, infection, or other conditions that affect the immune system.
Choice B reason: Monitoring the client's temperature every 4 hr is an appropriate action for a nurse to take for a client who has a high WBC count. A fever is a common sign of infection or inflammation, and it may require further intervention, such as antibiotics or antipyretics.
Choice C reason: Administering an antihistamine as prescribed is not related to a high WBC count. Antihistamines are used to treat allergic reactions, which may cause a low WBC count due to the release of histamine from mast cells.
Choice D reason: Encouraging the client to increase fluid intake is not specific to a high WBC count. Fluid intake should be based on the client's hydration status, urine output, and other factors. Increasing fluid intake may help flush out toxins or bacteria, but it is not a priority action for a client who has a high WBC count.
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