The nurse is caring for a client who is diagnosed with bacterial meningitis. Which assessment finding would be an immediate concern for the nurse?

Periodic nystagmus

Severe unrelenting headaches

Photophobia during the day

Decreased level of consciousness

Answer and Explanation

The Correct Answer is D

Choice A: Periodic Nystagmus

Nystagmus, which is characterized by involuntary eye movements, can be a symptom of various neurological conditions, including bacterial meningitis. However, it is not typically an immediate concern compared to other symptoms. Nystagmus indicates potential issues with the brainstem or cerebellum, but it does not directly threaten the patient’s life or indicate a rapid deterioration in condition. Therefore, while it is important to monitor, it is not the most urgent finding.

Choice B: Severe Unrelenting Headaches

Severe headaches are a common symptom of bacterial meningitis due to the inflammation of the meninges. While they are extremely painful and distressing for the patient, they are not as immediately life-threatening as a decreased level of consciousness. Headaches indicate increased intracranial pressure, which is serious, but the priority is to address symptoms that indicate a more rapid decline in neurological function.

Choice C: Photophobia During the Day

Photophobia, or sensitivity to light, is another common symptom of meningitis. It results from the irritation of the meninges and is often accompanied by headaches. While photophobia can be very uncomfortable and indicative of meningitis, it is not an immediate concern compared to a decreased level of consciousness. Photophobia does not directly indicate a life-threatening situation.

Choice D: Decreased Level of Consciousness

A decreased level of consciousness is the most immediate concern for a nurse caring for a patient with bacterial meningitis. This symptom indicates a significant and potentially rapid decline in the patient’s neurological status. It can be a sign of increased intracranial pressure, brain swelling, or other severe complications. Immediate medical intervention is required to prevent further deterioration and potential fatality. Monitoring and addressing changes in consciousness are critical in managing bacterial meningitis effectively.

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Correct Answer is B

Explanation

Choice A: Tachycardia

Tachycardia, defined as a heart rate exceeding 100 beats per minute, can affect the accuracy of pulse oximetry readings. When the heart beats too quickly, it may not fill with enough blood between beats, leading to reduced perfusion and oxygen delivery to tissues. However, while tachycardia can influence the readings, it is not the most significant factor compared to hypotension.

Choice B: Hypotension

Hypotension, or low blood pressure, significantly impacts pulse oximetry accuracy. When blood pressure is low, there is reduced perfusion to peripheral tissues, including the extremities where pulse oximeters are typically placed. This reduced perfusion can lead to inaccurate readings, as the device may not detect sufficient blood flow to measure oxygen saturation accurately. Hypotension is a critical factor that can alter pulse oximetry values, making it the most relevant choice.

Choice C: Tachypnea

Tachypnea, or rapid breathing, can affect oxygen levels in the blood but does not directly interfere with the pulse oximeter’s ability to measure oxygen saturation. While it indicates respiratory distress and can lead to hypoxemia, the pulse oximeter can still provide accurate readings unless accompanied by other factors like low perfusion.

Choice D: Fever

Fever can cause peripheral vasodilation, which might theoretically affect pulse oximetry readings by altering blood flow to the extremities. However, this effect is generally minimal compared to the impact of hypotension. Fever alone is unlikely to cause significant inaccuracies in pulse oximetry measurements.

Correct Answer is ["31"]

Explanation

Step 1: Calculate the total infusion time in minutes.

8 hours × 60 minutes/hour = 480 minutes

Result at each step = 480 minutes

Step 2: Calculate the total number of drops to be infused.

1,000 mL × 15 drops/mL = 15,000 drops

Result at each step = 15,000 drops

Step 3: Calculate the infusion rate in drops per minute.

15,000 drops ÷ 480 minutes = 31.25 drops/minute

Result at each step = 31.25 drops/minute

Step 4: Round to the nearest whole number if necessary.

31.25 drops/minute rounds to 31 drops/minute

Result at each step = 31 drops/minute

Therefore, the nurse should run the IV infusion at a rate of 31 drops per minute.

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The nurse is caring for a client who is diagnosed with bacterial meningitis. Which assessment finding would be an immediate concern for the nurse?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Exhibits You retrieved regular insulin 100 units in 1 ml. How many ml should you administer? Note Enter ONLY the number DO NOT enter the unit(s) of measurement

Correct Answer is ["31"]

Explanation

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