Nokea
A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis. Which question should the nurse ask?
- A. Do you live in a crowded residence?
- B. When was your last tetatuss vaccination?
- C. Have you had any viral infections recently?
- D. Have you had any viral infections in the last month?
Correct Answer: A
Rationale: Living in a crowded residence increases the risk of bacterial meningitis due to close contact and potential spread of infection. Questions about tetanus vaccination or recent viral infections are less relevant to the focused history for bacterial meningitis.
You may also like to solve these questions
After teaching a client newly diagnosed with spieplety, the nurse assesses the clients understanding. Which statement by the client indicates a need for additional teaching?
- A. I will not drive a motor vehicle while taking this medication.
- B. While taking my epilepety medications, I will not drink any alcoholic beverages.
- C. I will tell my doctor about my prescription and over-the-counter medications.
- D. If I am nauseated, I will not take my epilepety medication.
Correct Answer: D
Rationale: The nurse must emphasize that antiepileptic drugs must be taken even if the client is nauseous. Discontinuing the medication can predispose the client to seizure activity and status epilepticus. The client should not drink alcohol while taking seizure medications. The client should wear a medical alert bracelet and inform the doctor about all medications to prevent complications of polypharmacy.
A nurse plans care for a client with Parkinson disease. Which intervention should the nurse include in this clients plan of care?
- A. Ambulate the client in the hallway twice a day.
- B. Teach the client pursed-lip breathing techniques.
- C. Keep the head of the bed at 30 degrees or greater.
- D. Provide small, frequent meals to prevent aspiration.
Correct Answer: C
Rationale: Elevation of the head of the bed will help prevent aspiration, a common risk in Parkinson disease due to swallowing difficulties. Ambulation in the hallway prevents venous thrombosis but does not address aspiration. Pursed-lip breathing is not relevant, and small, frequent meals are beneficial but not the primary intervention listed.
A nurse assesses a client who is experiencing a cluster headache. Which clinical manifestations should the nurse expect to find? (Select all that apply.)
- A. Ipsilateral tearing
- B. Miosis
- C. Rhinorrhea
- D. Neck and shoulder tenderness
- E. Eyelid edema
Correct Answer: A,B,E
Rationale: Cluster headache is usually accompanied by ipsilateral tearing, miosis, rhinorrhea or nasal congestion, ptosis, eyelid edema, and facial sweating. Abrupt loss of consciousness, neck and shoulder tenderness, and exophthalmos are not associated with cluster headaches.
A nurse is caring for a client with meningitis. Which laboratory values should the nurse monitor to identify potential complications of this disorder? (Select all that apply.)
- A. Sodium levels
- B. Clotting factors
- C. White blood cell count
- D. C-reactive protein
- E. Liver enzymes
Correct Answer: A,B
Rationale: Inflammation from meningitis can stimulate the hypothalamus, leading to excessive antidiuretic hormone production, causing syndrome of inappropriate antidiuretic hormone (SIADH); thus, sodium levels should be monitored. Systemic inflammatory response syndrome (SIRS) can lead to coagulopathy and disseminated intravascular coagulation, requiring monitoring of clotting factors. Other values are not specific to meningitis complications.
A nurse assesses a client who is at risk for secondary seizures. Which conditions place the client at risk? (Select all that apply.)
- A. Brain lesion from a tumor
- B. Metabolic disorder
- C. Acute alcohol withdrawal
- D. History of stroke
- E. Multiple sclerosis
Correct Answer: A,B,C,D
Rationale: Clients at risk for secondary seizures include those with brain lesions from tumors or trauma, metabolic disorders, acute alcohol withdrawal, electrolyte disturbances, high fever, stroke, or substance abuse. Multiple sclerosis and chronic pulmonary disease are not typically associated with secondary seizures.