Nokea
The nurse is assessing the client with a tentative diagnosis of meningitis. Which findings should the nurse associate with meningitis? Select all that apply.
- A. Nuchal rigidity
- B. Severe headache
- C. Pill-rolling tremor
- D. Photophobia
- E. Lethargy
Correct Answer: A,B,D,E
Rationale: Irritation of the meninges causes nuchal rigidity (stiff neck). Irritation of the meninges causes severe headache. Pill-rolling tremors are associated with PD. Irritation of the meninges causes photophobia (light irritates the eyes). Lethargy, pathological state of sleepiness or unresponsiveness, indicates a decreased level of consciousness which is associated with meningitis.
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The nurse reviews the chart of the client who had a T12 SCI 12 years ago and is receiving baclofen through an intrathecal infusion pump. Which chart information in the exhibit is most important for the nurse to discuss with the HCP?
- A. Assessment findings
- B. Orthostatic hypotension
- C. Laboratory test results
- D. Prescribed medications
Correct Answer: A
Rationale: Exaggerated spasticity, muscle rigidity, and tinnitus are adverse effects of baclofen (Lioresal) that the nurse should discuss with the HCP. The client had a minimal drop in BP from lying to standing and does not have orthostatic hypotension. The WBC and liver enzymes are WNL. The glucose is not significantly elevated and would not warrant notifying the HCP. All prescribed medications are appropriate for the client who has a T12 SCI.
Which client should the nurse assess first after receiving the shift report?
- A. The client diagnosed with a stroke who has right-sided paralysis.
- B. The client diagnosed with meningitis who complains of photosensitivity.
- C. The client with a brain tumor who has projectile vomiting.
- D. The client with epilepsy who complains of tender gums.
Correct Answer: C
Rationale: Projectile vomiting (C) in a brain tumor suggests increased ICP, a life-threatening condition requiring immediate assessment. Paralysis (A), photosensitivity (B), and tender gums (D) are less urgent.
Which client statement indicates a need for further teaching about warfarin therapy?
- A. I'll avoid eating large amounts of spinach.'
- B. I'll take my medication at the same time daily.'
- C. I can take ibuprofen for headaches.'
- D. I'll report any unusual bruising.'
Correct Answer: C
Rationale: Ibuprofen increases bleeding risk with warfarin; the client should use acetaminophen instead.
The client comes to the clinic and reports a sudden drooping of the left side of the face and complains of pain in that area. The nurse notes that the client cannot wrinkle the forehead or close the left eye. Which condition should the nurse suspect?
- A. Bell's palsy.
- B. Right-sided stroke.
- C. Tetany.
- D. Mononeuropathy.
Correct Answer: A
Rationale: Bell’s palsy (A) causes unilateral facial drooping, inability to wrinkle the forehead, and eye closure issues due to facial nerve paralysis. Right-sided stroke (B) affects the opposite side, tetany (C) involves muscle spasms, and mononeuropathy (D) is less specific.
The client diagnosed with ALS is prescribed an antiglutamate, riluzole (Rilutek). Which instruction should the nurse discuss with the client?
- A. Take the medication with food.
- B. Do not eat green, leafy vegetables.
- C. Use SPF 30 when going out in the sun.
- D. Report any febrile illness.
Correct Answer: D
Rationale: Riluzole can cause liver toxicity, and febrile illness (D) may indicate infection or drug reaction, requiring prompt reporting. Taking with food (A) is not required, green vegetables (B) are unrelated, and sun protection (C) is not specific.