Nokea
The client is diagnosed with meningococcal meningitis. Which preventive measure would the nurse expect the health-care provider to order for the significant others in the home?
- A. The Haemophilus influenzae vaccine.
- B. Antimicrobial chemoprophylaxis.
- C. A 10-day dose pack of corticosteroids.
- D. A gamma globulin injection.
Correct Answer: B
Rationale: Close contacts of meningococcal meningitis patients require antimicrobial chemoprophylaxis (B), such as rifampin, to prevent infection. Vaccines (A) are not for immediate prophylaxis, corticosteroids (C) treat inflammation, and gamma globulin (D) is not indicated.
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Spinal precautions are ordered for the client who sustained a neck injury during an MVA. The client has yet to be cleared that there is no cervical fracture. Which action is the nurse’s priority when receiving the client in the ED?
- A. Assessing the client using the Glasgow Coma Scale (GCS)
- B. Assessing the level of sensation in the client’s extremities
- C. Checking that the cervical collar was correctly placed by EMS
- D. Applying antiembolism hose to the client’s lower extremities
Correct Answer: C
Rationale: The nurse should determine the neurological status using the GCS, but this is not the priority. The nurse should assess sensation status at intervals to determine neurological injury progression, but this is not the priority. Maintaining the correct placement of the cervical collar will keep the client’s head and neck in a neutral position and prevent further injury if a spinal fracture or SCI is present. Because ensuring that the cervical collar is correctly placed will prevent further injury, it is priority. Applying antiembolism hose is an intervention to prevent thromboembolic complications, but this is not the priority.
Which instruction should the nurse include for a client taking phenytoin (Dilantin)?
- A. Brush teeth gently to prevent gum hyperplasia.
- B. Avoid grapefruit juice.
- C. Take the medication with milk.
- D. Increase dietary sodium intake.
Correct Answer: A
Rationale: Phenytoin can cause gingival hyperplasia; gentle brushing helps prevent gum complications.
If the diagnosis is accurate, which assessment findings should the nurse document? Select all that apply.
- A. Photophobia
- B. A stiff neck
- C. Muscle weakness
- D. Diarrhea
- E. Vertigo
- F. Fever
Correct Answer: A,B,F
Rationale: Meningitis commonly presents with photophobia, stiff neck (nuchal rigidity), and fever due to inflammation of the meninges. Muscle weakness, diarrhea, and vertigo are not typically associated with meningitis.
The client is at risk for septic emboli after being diagnosed with meningococcal meningitis. Which action by the nurse directly addresses this risk?
- A. Monitoring vital signs and oxygen saturation levels hourly
- B. Planning to give meningococcal polysaccharide vaccine
- C. Assessing neurological function with the Glasgow Coma Scale q2h
- D. Completing a thorough vascular assessment of all extremities q2h
Correct Answer: D
Rationale: Monitoring VS is indicated but does not address the complication of septic emboli. Immunization with the meningococcal polysaccharide vaccine (Menomune) is a preventive measure against meningitis and would not be included in treatment. Frequent neurological assessments are indicated but do not address the complication of septic emboli. Frequent vascular assessments will detect vascular compromise secondary to septic emboli. Early detection allows for interventions that will prevent gangrene and possible loss of limb.
The client has undergone a craniotomy for a brain tumor. Which data indicate a complication of this surgery?
- A. The client complains of a headache at '3' to '4' on a 1-to-10 scale.
- B. The client has an intake of 1,000 mL and an output of 3,500 mL.
- C. The client complains of a raspy, sore throat.
- D. The client experiences dizziness when trying to get up too quickly.
Correct Answer: B
Rationale: Significant output (3,500 mL) compared to intake (1,000 mL, B) suggests diabetes insipidus, a complication of craniotomy due to pituitary dysfunction. Mild headache (A), sore throat (C), and orthostatic dizziness (D) are less concerning.