Nokea
The nurse is caring for the client with encephalitis. Which intervention should the nurse implement first if the client is experiencing a complication?
- A. Examine pupil reactions to light.
- B. Assess level of consciousness.
- C. Observe for seizure activity.
- D. Monitor vital signs every shift.
Correct Answer: B
Rationale: Level of consciousness (B) is the first assessment for complications in encephalitis, indicating neurological status. Pupil reactions (A), seizures (C), and vital signs (D) follow.
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Which potential pituitary complication should the nurse assess for in the client diagnosed with a traumatic brain injury (TBI)?
- A. Diabetes mellitus type 2 (DM 2).
- B. Seizure activity.
- C. Syndrome of inappropriate antidiuretic hormone (SIADH).
- D. Cushing's disease.
Correct Answer: C
Rationale: TBI can damage the pituitary, causing SIADH (C), leading to fluid retention and hyponatremia. DM2 (A) is unrelated, seizures (B) are neurological, and Cushing’s (D) is less common post-TBI.
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.
The nurse plans to show the spouse of the client with a suspected epidural hematoma where the epidural hematoma occurs in the brain. Which illustration should the nurse select when teaching the client’s spouse?
- A. Illustration A
- B. Illustration B
- C. Illustration C
- D. Illustration D
Correct Answer: B
Rationale: This illustration shows a subdural hematoma, which occurs below the dura. This illustration shows an epidural hematoma, which occurs between the skull and the dura. This illustration shows normal brain structures. An intracerebral hematoma occurs within the brain tissue and can result in brain herniation as shown in this illustration.
The public health nurse is giving a lecture on potential outbreaks of infectious meningitis. Which population is most at risk for an outbreak?
- A. Clients recently discharged from the hospital.
- B. Residents of a college dormitory.
- C. Individuals who visit a third world country.
- D. Employees in a high-rise office building.
Correct Answer: B
Rationale: College dormitory residents (B) are at high risk for meningococcal meningitis due to close living conditions and shared spaces. Hospital discharges (A), travel (C), or office workers (D) are less specific risks.
When the nurse observes that the client has difficulty swallowing the capsule of medication, which action is best to take?
- A. Soak the capsule in water until soft.
- B. Tell the client to chew the capsule.
- C. Moisten the capsule in the client's mouth.
- D. Offer water before giving the capsule.
Correct Answer: D
Rationale: Offering water before giving the capsule aids swallowing without altering the medication's integrity.