Nokea
The nurse is caring for a client with bacterial meningitis. Which assessment finding(s) is most important in determining nursing care for this client? Select all that apply.
- A. Cloudy cerebral spinal fluid
- B. Pain and stiffness of the extremities
- C. Purpura of hands and feet
- D. Low white blood cell (WBC) count
- E. Low red blood cell (RBC) count
- F. Low antidiuretic hormone (ADH) levels
Correct Answer: A,C
Rationale: The cerebral spinal fluid (CSF) will be cloudy if bacterial meningitis is the causative agent. Purpura indicates a serious complication of bacterial meningitis (disseminated intravascular coagulation) is occurring and may place the client at risk for amputation of those parts. Pain and stiffness of the extremities is not indicative of meningitis. A rise in RBCs, WBCs, and ADH would be expected.
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The school nurse notes a 6-year-old running across the playground with friends. The child stops in midstride, freezing for a few seconds. Then the child resumes running across the playground. The school nurse suspects what in this child?
- A. An absence seizure
- B. A myoclonic seizure
- C. A partial seizure
- D. A tonic-clonic seizure
Correct Answer: A
Rationale: Absence seizures, formerly referred to as petit mal seizures, are more common in children. They are characterized by a brief loss of consciousness during which physical activity ceases. The person stares blankly; the eyelids flutter; the lips move; and slight movement of the head, arms, and legs occurs. These seizures typically last for a few seconds, and the person seldom falls to the ground. Because of their brief duration and relative lack of prominent movements, these seizures often go unnoticed. People with absence seizures can have them many times a day. Partial, or focal, seizures begin in a specific area of the cerebral cortex. Both myoclonic and tonic-clonic seizures involve jerking movements.
A client diagnosed with Huntington disease is on a disease-modifying drug regimen and has a urinary catheter in place. Which potential complication is the highest priority for the nurse while monitoring the client?
- A. Severe depression
- B. Choreiform movements
- C. Urinary tract infection
- D. Emotional apathy
Correct Answer: C
Rationale: Because all disease-modifying drug regimens for Huntington disease can decrease immune cells and infection protection, it is most important for the nurse to assess for acquired infections such as urinary tract infections, especially if the client is catheterized. Severe depression is common and can lead to suicide. Symptoms of Huntington disease develop slowly and include mental apathy and emotional disturbances, choreiform movements (uncontrollable writhing and twisting of the body), grimacing, difficulty chewing and swallowing, speech difficulty, intellectual decline, and loss of bowel and bladder control. Assessing for these other conditions is appropriate but not as important as assessing for urinary tract infection in the client on a disease-modifying drug regimen with a urinary catheter in place.
The nurse is caring for a client newly diagnosed with Parkinson disease. Which topic is most important for the nurse to include in the teaching plan for this client?
- A. Involvement with diversion activities
- B. Enhancement of the immune system
- C. Establishing balanced nutrition
- D. Maintaining a safe environment
Correct Answer: D
Rationale: The primary focus in caring for Parkinson disease is on maintaining a safe environment. Parkinson disease often has a propulsive gait, characterized by a tendency to take increasingly quicker steps while walking and an inability to stop abruptly without losing balance. Prevention of communicable diseases and establishing a balanced nutrition is encouraged with any chronic disorder. Diversional activities can be helpful in times of stress but not a priority.
The nurse is caring for a 30-year-old client diagnosed with amyotrophic lateral sclerosis (ALS). Which statement by the client would indicate a need for more teaching from the nurse?
- A. I will have progressive muscle weakness.
- B. I will lose strength in my arms.
- C. My children are at greater risk to develop this disease.
- D. I need to remain active for as long as possible.
Correct Answer: C
Rationale: There is no known cause for ALS, and no reason to suspect genetic inheritance. ALS usually begins with muscle weakness of the arms and progresses. The client is encouraged to remain active for as long as possible to prevent respiratory complications.
The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased intracranial pressure (ICP). What neurologic sequelae might this client develop?
- A. Damage to the nerves that facilitate vision and hearing
- B. Damage to the vagal nerve
- C. Damage to the olfactory nerve
- D. Damage to the facial nerve
Correct Answer: A
Rationale: Neurologic sequelae in survivors include damage to the cranial nerves that facilitate vision and hearing. Sequelae to meningitis do not include damage to the vagal nerve, the olfactory nerve, or the facial nerve.