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The nurse is assessing the client admitted with encephalitis. Which data require immediate nursing intervention? The client has bilateral facial palsies.
- A. The client has a recurrent temperature of 100.6°F.
- B. The client has a decreased complaint of headache.
- C. The client comments that the meal has no taste.
Correct Answer: B
Rationale: A fever of 100.6°F (B) in encephalitis may indicate worsening infection or inflammation, requiring immediate intervention. Decreased headache (C) suggests improvement, and taste loss (D) is less urgent. Facial palsies are noted but not an option.
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Based on the nurse's knowledge, which characteristic is found in Alzheimer's disease that distinguishes it from other dementias?
- A. Destruction of brain cells from hypoxia
- B. Destruction of brain cells from a stroke
- C. Neurofibrillary tangles and plaques in the brain
- D. A superficial infection in the meninges of the brain
Correct Answer: C
Rationale: Neurofibrillary tangles and amyloid plaques are hallmark pathological features of Alzheimer's disease.
Which statement best describes the scientific rationale for alternating a nonnarcotic antipyretic and a nonsteroidal anti-inflammatory drug (NSAID) every two (2) hours to a female client diagnosed with bacterial meningitis?
- A. This regimen helps to decrease the purulent exudate surrounding the meninges.
- B. These medications will decrease intracranial pressure and brain metabolism.
- C. These medications will increase the client’s memory and orientation.
- D. This will help prevent a yeast infection secondary to antibiotic therapy.
Correct Answer: B
Rationale: Alternating antipyretics and NSAIDs (B) reduces fever and inflammation, lowering ICP and brain metabolism in meningitis. Exudate (A) is addressed by antibiotics, memory/orientation (C) is not directly affected, and yeast infections (D) are unrelated.
In assessing a client with a Thoracic SCI, which clinical manifestation would the nurse expect to find to support the diagnosis of neurogenic shock?
- A. No reflex activity below the waist.
- B. Inability to move upper extremities.
- C. Complaints of a pounding headache.
- D. Hypotension and bradycardia.
Correct Answer: D
Rationale: Neurogenic shock in thoracic SCI results from loss of sympathetic tone, leading to hypotension and bradycardia (D). No reflex activity (A) indicates spinal shock, upper extremity paralysis (B) occurs in cervical SCI, and headache (C) is unrelated.
The nurse is assessing the client following a closed head injury. When applying nailbed pressure, the client’s body suddenly stiffens, the eyes roll upward, and there is an increase in salivation and loss of swallowing reflex. Which observation should the nurse document?
- A. Decerebrate posturing observed
- B. Decorticate posturing observed
- C. Positive Kernig’s sign observed
- D. Seizure activity observed
Correct Answer: D
Rationale: Decerebrate posture involves rigid extension of the arms and legs, downward pointing of the toes, and backward arching of the head. Decorticate posture involves rigidity, flexion of the arms toward the body with the wrists and fingers clenched and held on the chest, and the legs extended. A positive Kernig’s sign is flexing the leg at the hip and then raising the leg into extension. Severe head and neck pain occurs. Body stiffening, eyes rolled upward, increase in salivation, and a loss of swallowing reflex are signs consistent with the tonic phase of a tonic-clonic seizure. This phase is followed by the clonic phase with violent muscle contractions.
The chief executive officer (CEO) of a large manufacturing plant presents to the occupational health clinic with chronic rhinitis and requesting medication. On inspection, the nurse notices holes in the septum that separates the nasal passages. The nurse also notes dilated pupils and tachycardia. The facility has a 'No Drug' policy. Which intervention should the nurse implement?
- A. Prepare to complete a drug screen urine test.
- B. Discuss the client’s use of illegal drugs.
- C. Notify the client’s supervisor about the situation.
- D. Give the client an antihistamine and say nothing.
Correct Answer: A
Rationale: Nasal septal perforation, dilated pupils, and tachycardia suggest cocaine use. A drug screen (A) objectively confirms substance use while maintaining confidentiality. Discussing drug use (B) is premature, notifying the supervisor (C) breaches confidentiality, and ignoring findings (D) is unethical.