Nokea
A patient is admitted through the ED with suspected St. Louis encephalitis. The unique clinical feature of St. Louis encephalitis will make what nursing action a priority?
- A. Serial assessments of hemoglobin levels
- B. Blood glucose monitoring
- C. Close monitoring of fluid balance
- D. Assessment of pain along dermatomes
Correct Answer: C
Rationale: St. Louis encephalitis is associated with SIADH, causing hyponatremia, so monitoring fluid balance is critical. Hemoglobin, glucose, and dermatomal pain are not specific to this condition.
You may also like to solve these questions
The nurse is preparing to provide care for a patient diagnosed with myasthenia gravis. The nurse should know that the signs and symptoms of the disease are the result of what?
- A. Genetic dysfunction
- B. Upper and lower motor neuron lesions
- C. Decreased conduction of impulses in an upper motor neuron lesion
- D. A lower motor neuron lesion
Correct Answer: D
Rationale: Myasthenia gravis results from a lower motor neuron lesion at the myoneural junction, causing muscle weakness. It is not genetic, nor does it involve upper motor neurons.
A 73-year-old man comes to the clinic complaining of weakness and loss of sensation in his feet and legs. Assessment of the patient shows decreased reflexes bilaterally. Why would it be a challenge to diagnose a peripheral neuropathy in this patient?
- A. Older adults are often vague historians.
- B. The elderly have fewer peripheral nerves than younger adults.
- C. Many older adults are hesitant to admit that their body is changing.
- D. Many symptoms can be the result of normal aging process.
Correct Answer: D
Rationale: Symptoms like decreased reflexes in peripheral neuropathy can mimic normal aging, complicating diagnosis. Older adults do not necessarily have fewer nerves or withhold information.
A male patient presents to the clinic complaining of a headache. The nurse notes that the patient is guarding his neck and tells the nurse that he has stiffness in the neck area. The nurse suspects the patient may have meningitis. What is another well-recognized sign of this infection?
- A. Negative Brudzinski's sign
- B. Positive Kernig's sign
- C. Hyperpatellar reflex
- D. Sluggish pupil reaction
Correct Answer: B
Rationale: A positive Kernig's sign, where leg extension causes pain due to meningeal irritation, is a classic sign of meningitis. Brudzinski's sign is positive, not negative, and reflexes or pupil reactions are not typical signs.
The nurse is caring for a 77-year-old woman with MS. She states that she is very concerned about the progress of her disease and what the future holds. The nurse should know that elderly patients with MS are known to be particularly concerned about what variables? Select all that apply.
- A. Possible nursing home placement
- B. Pain associated with physical therapy
- C. Increasing disability
- D. Becoming a burden on the family
- E. Loss of appetite
Correct Answer: A,C,D
Rationale: Elderly MS patients worry about increasing disability, family burden, and potential nursing home placement due to progressive loss of function. Pain from therapy and appetite loss are not primary concerns.
The nurse is discharging a patient home after surgery for trigeminal neuralgia. What advice should the nurse provide to this patient in order to reduce the risk of injury?
- A. Avoid watching television or using a computer for more than 1 hour at a time.
- B. Use OTC antibiotic eye drops for at least 14 days.
- C. Avoid rubbing the eye on the affected side of the face.
- D. Rinse the eye on the affected side with normal saline daily for 1 week.
Correct Answer: C
Rationale: Surgery may cause sensory loss, making eye rubbing dangerous as pain from injury may not be felt. TV use, antibiotic drops, and saline rinses are not relevant to injury prevention.