Nokea
The community health nurse is developing a program to decrease the incidence of meningitis in adolescents and young adults. Which of the following nursing actions is most important?
- A. Vaccinate 11- and 12-year-old children against Haemophilus influenzae.
- B. Emphasize the importance of handwashing to prevent spread of infection.
- C. Immunize adolescents and postsecondary students against Neisseria meningitidis.
- D. Encourage adolescents and young adults to avoid crowded areas in the winter.
Correct Answer: C
Rationale: The Neisseria meningitidis vaccination is recommended for children ages 11 and 12, unvaccinated teens entering high school, and postsecondary students. Handwashing may help decrease the spread of bacteria, but it is not as effective as immunization. Vaccination with Haemophilus influenzae is for infants and toddlers. Because adolescents and young adults are in school or the workplace, avoiding crowds is not realistic.
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The nurse is admitting a patient who has a tumour of the right frontal lobe. Which of the following findings should the nurse expect to observe?
- A. Judgement changes
- B. Expressive aphasia
- C. Right-sided weakness
- D. Difficulty swallowing
Correct Answer: A
Rationale: The frontal lobes control intellectual activities such as judgement. Speech is controlled in the parietal lobe. Weakness and hemiplegia occur on the contralateral side from the tumour. Swallowing is controlled by the brain stem.
The nurse is caring for a patient who has just been admitted with meningococcal meningitis. Which of the following observations requires the nurse to act?
- A. The bedrails at the head and foot of the bed are both elevated.
- B. The patient receives a regular diet from the dietary department.
- C. The student nurse goes into the patient's room without a mask.
- D. The lights in the patient's room are turned off and the blinds are shut.
Correct Answer: C
Rationale: Meningococcal meningitis is spread by respiratory secretions, so it is important to maintain respiratory isolation as well as standard precautions for at least the first 48 hours. Because the patient may be confused and weak, bedrails should be elevated at both the foot and head of the bed. Low light levels in the room decrease pain caused by photophobia. Nutrition is an important aspect of care in a patient with meningitis.
The nurse is assessing a patient with a head injury. Which of the following assessments should the nurse complete first?
- A. Obtain oxygen saturation.
- B. Check pupil reaction to light.
- C. Palpate the head for hematoma.
- D. Assess Glasgow Coma Scale (GCS).
Correct Answer: A
Rationale: Airway patency and breathing are the most vital functions and should be assessed first. The neurological assessments should be accomplished next and the health and medication history last.
The nurse is caring for a patient with possible cerebral edema who has a serum sodium level of 115 mmol/L, a decreasing level of consciousness (LOC), and has a headache. Which of the following prescribed interventions should the nurse implement first?
- A. Draw blood for arterial blood gases (ABGs).
- B. Administer 5% hypertonic saline intravenously.
- C. Administer acetaminophen 650 mg orally.
- D. Send patient for computed tomography (CT) of the head.
Correct Answer: B
Rationale: The patient's low sodium indicates that hyponatremia may be causing the cerebral edema, and the nurse's first action should be to correct the low sodium level. Acetaminophen will have minimal effect on the headache because it is caused by cerebral edema and increased intracranial pressure (ICP). Drawing ABGs and obtaining a CT scan may add some useful information, but the low sodium level may lead to seizures unless it is addressed quickly.
A nurse is providing care for an unconscious patient with a head injury prescribed IV mannitol. Which of the following parameters is best for the nurse to monitor to determine if the mannitol has been effective?
- A. Hematocrit
- B. Blood pressure
- C. Oxygen saturation
- D. Intracranial pressure
Correct Answer: D
Rationale: Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial pressure. It may initially reduce hematocrit and increase blood pressure, but these are not the best parameters for evaluation of the effectiveness of the drug. Oxygen saturation will not directly improve as a result of mannitol administration.