Nokea
The client is reporting neck pain, fever, and a headache. The nurse elicits a positive Kernig's sign. Which diagnostic test procedure should the nurse anticipate the HCP ordering to confirm a diagnosis?
- A. A computed tomography (CT).
- B. Blood cultures times two (2).
- C. Electromyogram (EMG).
- D. Lumbar puncture (LP).
Correct Answer: D
Rationale: Neck pain, fever, headache, and positive Kernig’s sign suggest meningitis. A lumbar puncture (D) confirms the diagnosis via CSF analysis. CT (A) may precede LP, blood cultures (B) are supportive, and EMG (C) is unrelated.
You may also like to solve these questions
The nurse is teaching the client who is scheduled for an outpatient EEG. Which instruction should the nurse include?
- A. Remove all hairpins before coming in for the EEG test.
- B. Avoid eating or drinking at least 6 hours prior to the test.
- C. Some hair will be removed with a razor to place electrodes.
- D. Have blood drawn for a glucose level 2 hours before the test.
Correct Answer: A
Rationale: In an EEG, electrodes are placed on the scalp over multiple areas of the brain to detect and record patterns of electrical activity. Preparation includes clean hair without any objects in the hair to prevent inaccurate test results. The client should not be NPO since a usual glucose level is important for normal brain functioning. The scalp will not be shaved; the electrodes are applied with paste. There is no indication to have a serum glucose drawn before the test.
The client has been newly diagnosed with epilepsy. Which discharge instructions should be taught to the client? Select all that apply.
- A. Keep a record of seizure activity.
- B. Take tub baths only; do not take showers.
- C. Avoid over-the-counter medications.
- D. Have anticonvulsant medication serum levels checked regularly.
- E. Do not drive alone; have someone in the car.
Correct Answer: A,C,D,E
Rationale: Recording seizures (A) helps track treatment efficacy, avoiding OTC medications (C) prevents interactions, regular serum levels (D) ensure therapeutic dosing, and not driving alone (E) ensures safety. Tub baths (B) pose a drowning risk and are not advised.
The client diagnosed with Parkinson’s disease (PD) is being admitted with a fever and patchy infiltrates in the lung fields on the chest x-ray. Which clinical manifestations of PD would explain these assessment data?
- A. Masklike facies and shuffling gait.
- B. Difficulty swallowing and immobility.
- C. Pill rolling of fingers and flat affect.
- D. Lack of arm swing and bradykinesia.
Correct Answer: B
Rationale: Difficulty swallowing and immobility (B) in PD increase aspiration risk, leading to pneumonia, which presents as fever and lung infiltrates. Other manifestations are less directly related to pulmonary complications.
The friend of an 18-year-old male client brings the client to the emergency department (ED). The client is unconscious and his breathing is slow and shallow. Which action should the nurse implement first?
- A. Ask the friend what drugs the client has been taking.
- B. Initiate an IV infusion at a keep-open rate.
- C. Call for a ventilator to be brought to the ED.
- D. Apply oxygen at 100% via nasal cannula.
Correct Answer: C
Rationale: Slow, shallow breathing in an unconscious client indicates respiratory depression, a life-threatening condition. Calling for a ventilator (C) ensures immediate airway support. Asking about drugs (A), starting an IV (B), and applying oxygen (D) follow airway management.
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.