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The nurse is assessing a patient with bacterial meningitis and obtains the following data. Which of the following findings should be reported immediately to the health care provider?
- A. The patient has a positive Kernig's sign.
- B. The patient complains of having a stiff neck.
- C. The patient's temperature is 38.3°C (100.9°F).
- D. The patient's blood pressure is 86/42 mm Hg.
Correct Answer: D
Rationale: Shock is a serious complication of meningitis, and the patient's low blood pressure indicates the need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernig's sign are expected with bacterial meningitis. The nurse should intervene to lower the temperature, but this is not as life-threatening as the hypotension.
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The nurse is caring for a patient admitted with bacterial meningitis who has a temperature of 38.9°C (102°F) and has prescriptions for all of the following collaborative interventions. Which action should the nurse take first?
- A. Administer ceftriaxone 1 g IV.
- B. Use a cooling blanket to lower temperature.
- C. Swab the nasopharyngeal mucosa for cultures.
- D. Give acetaminophen 650 mg PO.
Correct Answer: C
Rationale: Antibiotic therapy should be instituted rapidly in bacterial meningitis, but cultures must be done before antibiotics are started. As soon as the cultures are done, the antibiotic should be started. Hypothermia therapy and acetaminophen administration are appropriate but can be started after the other actions are implemented.
The nurse is caring for a patient who has a head injury and is diagnosed with a concussion. Which of the following actions should the nurse plan to take?
- A. Coordinate the transfer of the patient to the operating room.
- B. Provide discharge instructions about monitoring neurological status.
- C. Transport the patient to radiology for magnetic resonance imaging (MRI) of the brain.
- D. Arrange to admit the patient to the neurological unit for observation for 24 hours.
Correct Answer: B
Rationale: A patient with a minor head trauma is usually discharged with instructions about neurological monitoring and the need to return if neurological status deteriorates. MRI, hospital admission, or surgery is not indicated in a patient with a concussion.
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.
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.
The nurse is assessing a patient who is unconscious and applies a painful stimulus to the nail beds. The patient responds with internal rotation, adduction, and flexion of the arms. Which of the following terms should the nurse use when documenting the findings?
- A. Flexion withdrawal
- B. Localization of pain
- C. Decorticate posturing
- D. Decerebrate posturing
Correct Answer: C
Rationale: Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is generalized, it does not indicate localization of pain or flexion withdrawal.