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 C

Explanation

Choice A: Severe Hypertension

Severe hypertension can be a sign of increased intracranial pressure (ICP), but it is not typically the earliest sign. Hypertension often occurs as a compensatory mechanism to maintain cerebral perfusion pressure. While it is a significant finding, it usually follows other more immediate signs of increased ICP.

Choice B: Dilated and Nonreactive Pupils

Dilated and nonreactive pupils are a late sign of increased ICP and indicate severe brainstem compression. This finding suggests that the pressure has reached a critical level, leading to brain herniation. It is a very serious sign but not the earliest indicator of increasing ICP.

Choice C: Decreased Level of Consciousness

A decreased level of consciousness is often the earliest and most sensitive indicator of increasing ICP. Changes in consciousness can range from confusion and lethargy to complete unresponsiveness. This symptom reflects the brain’s response to increased pressure and reduced cerebral perfusion, making it a critical early sign that requires immediate attention.

Choice D: Projectile Vomiting

Projectile vomiting can occur with increased ICP due to pressure on the vomiting centers in the brainstem. However, it is not typically the earliest sign. Vomiting often accompanies other symptoms such as headache and changes in consciousness.

A. Metabolic alkalosis B. Respiratory alkalosis C. Respiratory acidosis D. Metabolic acidosis

Correct Answer is D

Explanation

Choice A Reason:

Metabolic alkalosis is characterized by an elevated pH (greater than 7.45) and an increased bicarbonate (HCO3) level. In this case, the pH is 7.30, indicating acidosis, and the HCO3 level is 18 mEq/L, which is below the normal range (22-26 mEq/L). Therefore, metabolic alkalosis is not the correct diagnosis.

Choice B Reason:

Respiratory alkalosis is indicated by a high pH (greater than 7.45) and a low PaCO2 (less than 35 mm Hg). Although the PaCO2 is low at 28 mm Hg, the pH is 7.30, indicating acidosis rather than alkalosis. Therefore, respiratory alkalosis is not the correct diagnosis.

Choice C Reason:

Respiratory acidosis is characterized by a low pH (less than 7.35) and an elevated PaCO2 (greater than 45 mm Hg). In this case, the pH is low, indicating acidosis, but the PaCO2 is also low at 28 mm Hg, which does not fit the criteria for respiratory acidosis. Therefore, respiratory acidosis is not the correct diagnosis.

Choice D Reason:

Metabolic acidosis is indicated by a low pH (less than 7.35) and a low bicarbonate (HCO3) level (less than 22 mEq/L). In this case, the pH is 7.30, indicating acidosis, and the HCO3 level is 18 mEq/L, which is below the normal range. The low PaCO2 of 28 mm Hg suggests a compensatory respiratory response to the metabolic acidosis. Therefore, metabolic acidosis is the correct diagnosis.

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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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