Nokea
What is the most appropriate action when a client with suspected meningitis presents with a positive Brudzinski sign?
- A. Place the client on their back and administer pain medication
- B. Place the client on their side and administer antibiotics
- C. Administer IV fluids and antibiotics
- D. Perform a lumbar puncture
Correct Answer: D
Rationale: The correct answer is D, perform a lumbar puncture. A positive Brudzinski sign indicates meningeal irritation, a hallmark of meningitis. A lumbar puncture is the gold standard for diagnosing meningitis by analyzing cerebrospinal fluid. Placing the client on their back without proper diagnosis or treatment delays could lead to serious complications. Option B is incorrect as antibiotics should be given after confirming the diagnosis. Option C is partially correct but does not address the need for a definitive diagnostic test. Option A is incorrect as pain medication alone does not address the underlying cause of meningitis.
You may also like to solve these questions
Which medication should be administered first for a client with acute asthma exacerbation?
- A. Albuterol
- B. Epinephrine
- C. Levalbuterol
- D. IV corticosteroids
Correct Answer: A
Rationale: Step-by-step rationale for choosing Albuterol as the correct answer:
1. Albuterol is a rapid-acting bronchodilator that provides immediate relief by relaxing the airway muscles during asthma exacerbation.
2. It is the first-line medication recommended by guidelines for acute asthma attacks due to its quick onset of action.
3. Albuterol helps in opening the airways, improving airflow, and relieving symptoms like shortness of breath and wheezing.
4. Epinephrine is not the first choice for asthma exacerbation as it can have more systemic side effects.
5. Levalbuterol is a similar medication to Albuterol but may not be as widely available or cost-effective.
6. IV corticosteroids are important for long-term control but take longer to show effects, making them less suitable as the initial treatment for acute exacerbation.
Which of the following statements about the mental health examination is true?
- A. A patient's family is the best resource for information about the patient's coping skills.
- B. It is usually sufficient to gather mental health information during the health history interview.
- C. It takes an enormous amount of extra time to integrate the mental health examination into the health history interview.
- D. It is usually necessary to perform a complete mental health examination to get a good idea of the patient's level of functioning.
Correct Answer: B
Rationale: The correct answer is B because the mental health examination should be integrated into the health history interview. This allows for a comprehensive understanding of the patient's mental health status. Gathering mental health information during the health history interview is crucial as it provides insight into the patient's current mental state, past history, and potential risk factors. This integrated approach is efficient and effective in assessing the patient's mental health needs.
A is incorrect because while family input can be valuable, it is not always the best or only resource for information about coping skills.
C is incorrect as integrating the mental health examination into the health history interview should not necessarily take an enormous amount of extra time if done efficiently.
D is incorrect as a complete mental health examination may not always be necessary to assess the patient's level of functioning; integrating mental health information into the health history interview can often provide sufficient insight.
What should the nurse assess first in a client with severe abdominal pain?
- A. Assess vital signs
- B. Administer oxygen
- C. Perform an ECG
- D. Monitor serum glucose levels
Correct Answer: A
Rationale: The correct answer is A: Assess vital signs. Vital signs provide crucial information on the client's overall condition and can help identify any life-threatening issues. Monitoring vital signs such as blood pressure, heart rate, respiratory rate, and temperature can guide immediate interventions and determine the urgency of further assessments or treatments. Administering oxygen (B) would be appropriate after assessing vital signs. Performing an ECG (C) may be indicated later but is not the priority in this acute situation. Monitoring serum glucose levels (D) is not typically the first assessment in a client with severe abdominal pain.
What is the most effective treatment for a client with acute respiratory distress syndrome (ARDS)?
- A. Administer oxygen
- B. Administer corticosteroids
- C. Monitor serum glucose
- D. Administer pain relief
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. ARDS is characterized by severe hypoxemia, and oxygen therapy is essential to improve oxygenation. Administering corticosteroids (B) is not recommended as they do not improve outcomes in ARDS. Monitoring serum glucose (C) is unrelated to the treatment of ARDS. Administering pain relief (D) is important for patient comfort but does not address the underlying hypoxemia in ARDS. Oxygen therapy is the primary treatment to support respiratory function and improve oxygen delivery in ARDS.
The nurse is performing a mental health assessment on a 5-year-old girl. Her parents are in the middle of a bitter divorce and are worried about the effect it is having on their daughter. Which of the following might lead the nurse to be concerned about the girl's mental health?
- A. She clings to her mother whenever the nurse is in the room.
- B. She appears angry and will not make eye contact with the nurse.
- C. Her mother states that the girl has begun to ride a tricycle around their yard.
- D. Her mother states that her daughter prefers to play with toddlers instead of kids her own age while in daycare.
Correct Answer: D
Rationale: The correct answer is D because it indicates a potential concern about the girl's mental health. This behavior may suggest a difficulty in socializing with peers of her own age, which could be a sign of emotional distress or developmental issues. This is concerning in the context of her parents' bitter divorce.
A: Clinging to her mother is a common behavior for a child going through a stressful situation, so it may not necessarily indicate a mental health issue.
B: Appearing angry and avoiding eye contact could also be a normal reaction to stress or discomfort.
C: Riding a tricycle is a typical activity for a 5-year-old and may not directly relate to mental health concerns.