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 C
Explanation
Choice A reason: Improved hydration is not a specific indicator of the effectiveness of the treatment for acute laryngotracheobronchitis. Hydration status should be monitored for any child with a respiratory infection, but it does not reflect the severity of the airway inflammation.
Choice B reason: Decreased temperature is not a specific indicator of the effectiveness of the treatment for acute laryngotracheobronchitis. Fever may or may not be present in this condition, and it does not correlate with the degree of airway obstruction.
Choice C reason: Decreased stridor is a specific indicator of the effectiveness of the treatment for acute laryngotracheobronchitis. Stridor is a high-pitched sound caused by turbulent airflow through a narrowed upper airway. It indicates a significant obstruction that can compromise breathing. A reduction in stridor means that the airway inflammation has subsided and the child can breathe more easily.
Choice D reason: Barking cough is not a specific indicator of the effectiveness of the treatment for acute laryngotracheobronchitis. Barking cough is a characteristic symptom of this condition, caused by the swelling of the vocal cords. It may persist for several days after the acute episode, even when the child is improving.
Correct Answer is D
Explanation
Choice A reason: Tetany is not a typical finding in an infant who is dehydrated. Tetany is a condition where the muscles contract involuntarily and cause spasms or cramps. It is usually caused by low calcium levels or alkalosis, not dehydration.
Choice B reason: Slow, bounding pulse is not a typical finding in an infant who is dehydrated. A slow, bounding pulse may indicate increased intracranial pressure or heart failure, not dehydration. A fast, weak pulse is more likely to occur in an infant who is dehydrated.
Choice C reason: Decreased temperature is not a typical finding in an infant who is dehydrated. A decreased temperature may indicate hypothermia or sepsis, not dehydration. A normal or slightly elevated temperature is more likely to occur in an infant who is dehydrated.
Choice D reason: Irritability is a typical finding in an infant who is dehydrated. Irritability indicates that the infant is uncomfortable and thirsty. It may also be a sign of cerebral dehydration, which can affect the infant's mental status and behavior.
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