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 B
Explanation
Choice A reason: Changes in the voice signal the beginning of puberty is incorrect, as voice changes usually occur in the middle or late stages of puberty, not the beginning. The first sign of puberty in boys is usually testicular enlargement, followed by pubic hair growth and penile enlargement.
Choice B reason: Growth spurts in height occur toward the end of mid-puberty is correct, as this is the typical pattern of growth for boys during puberty. Boys usually start their growth spurt later than girls, but grow faster and for a longer period of time.
Choice C reason: Puberty might be delayed if scrotal changes have not occurred by the age of 11 years is incorrect, as this is not a definitive indicator of delayed puberty. Puberty can vary widely among individuals, and some boys may start later than others without any underlying problem. Delayed puberty is usually diagnosed if there is no sign of puberty by the age of 14 years.
Choice D reason: Gynecomastia commonly occurs during late puberty is incorrect, as gynecomastia, or the enlargement of breast tissue in males, usually occurs in the early or middle stages of puberty, not the late stage. It is caused by hormonal changes and usually resolves on its own within a few months or years.
Correct Answer is A
Explanation
Choice A reason: Bacterial meningitis is an inflammation of the meninges, the membranes that cover the brain and spinal cord, caused by a bacterial infection. It can cause fever, headache, neck stiffness, photophobia, and altered mental status. The cerebrospinal fluid (CSF) analysis may show increased white blood cells, protein, and glucose. The nurse should assess the neck range of motion and the reaction to pupil assessment, as these may indicate increased intracranial pressure.
Choice B reason: Encephalitis is an inflammation of the brain tissue, usually caused by a viral infection. It can cause fever, headache, confusion, seizures, and focal neurological deficits. The CSF analysis may show increased white blood cells and protein, but normal glucose. The nurse should assess the level of consciousness and the neurological status, as these may indicate brain damage.
Choice C reason: Gastroenteritis is an inflammation of the stomach and intestines, usually caused by a viral or bacterial infection. It can cause nausea, vomiting, diarrhea, abdominal pain, and dehydration. The nurse should assess the gastrointestinal manifestations and the vital signs, as these may indicate fluid and electrolyte imbalance.
Choice D reason: Migraine is a type of headache that involves recurrent episodes of moderate to severe pain, usually on one side of the head, often accompanied by nausea, vomiting, and sensitivity to light and sound. The nurse should assess the location and duration of pain, the triggers and relievers, and the history of migraine. The CSF analysis is usually normal.
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