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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.
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The nurse has written a care plan for a client diagnosed with a brain tumor. Which is an important goal regarding self-care deficit?
- A. The client will maintain body weight within two (2) pounds.
- B. The client will execute an advance directive.
- C. The client will be able to perform three (3) ADLs with assistance.
- D. The client will verbalize feeling of loss by the end of the shift.
Correct Answer: C
Rationale: A realistic goal for self-care deficit is performing ADLs with assistance (C), addressing functional limitations due to the tumor. Weight maintenance (A), advance directives (B), and verbalizing loss (D) are not directly related to self-care.
The nurse is implementing interventions for the client who has increased ICP. The nurse knows that which result will occur if the increased ICP is left untreated?
- A. Displacement of brain tissue
- B. Increase in cerebral perfusion
- C. Increase in the serum pH level
- D. Leakage of cerebrospinal fluid
Correct Answer: A
Rationale: If untreated, increased ICP causes a shift in brain tissue and can result in irreversible brain damage and possibly death. ICP compresses structures within the cranium and leads to a decrease in cerebral perfusion, not increased perfusion. ICP compresses structures within the cranium and leads to acidosis; the pH level is decreased in acidosis. Leakage of CSF could occur if there were an opening in the subarachnoid space that could occur with trauma, but there is no indication that the increased ICP is due to trauma.
The nurse’s client with a T2 SCI is dysreflexic and has a BP of 170/90 mm Hg. Place the nurse’s interventions in the order that these should be performed.
- A. Elevate the HOB to 90 degrees.
- B. Lower the end of the bed so feet are dependent.
- C. Remove elastic stocking and other constricting devices; assess below the level of injury.
- D. Retake the blood pressure after being upright for 2 to 3 minutes.
- E. Administer a pm prescribed sublingual nifedipine for continued elevated BP.
- F. Perform digital removal of impacted stool (last BM found to be 10 days ago).
- G. Inform the HCP of the incident, measures taken, and client response.
Correct Answer: C,A,B,G,F,E,D
Rationale: Elevate the HOB to 90 degrees. This initial quick action may help lower the client’s BP. Lower the end of the bed so feet are dependent. Placing the feet lower than the head will help decrease blood return and may help lower the BP. Remove elastic stocking and other constricting devices; assess below the level of injury. Anything constricting below the level of injury can be the stimulus that precipitates autonomic dysreflexia. The nurse can assess for other precipitating factors, such as a full bladder, while removing constricting devices. Retake the BP after being upright for 2 to 3 minutes. Elevating the HOB, lowering the feet, and removing constricting devices may have lowered the BP. If not, further interventions are needed. Administer a pm prescribed sublingual nifedipine for continued elevated BP. If the BP remains elevated, the prescribed antihypertensive medication, such as nifedipine (Procardia), should be given next to quickly lower the BP. Perform digital removal of impacted stool (last BM found to be 10 days ago). Digitally removing stool impaction may cause a further spike in BP, so that should be completed after the BP medication is administered. Inform the HCP of the incident, measures taken, and client response. This is last because a pro antihypertensive medication had already been prescribed. Care of the client is priority.
The client asks the nurse, 'What causes Creutzfeldt-Jakob disease?' Which statement would be the nurse's best response?
- A. The person must have been exposed to an infected prion.'
- B. It is mad cow disease, and eating contaminated meat is the cause.'
- C. This disease is caused by a virus that is in stagnant water.'
- D. A fungal spore from the lungs infects the brain tissue.'
Correct Answer: A
Rationale: Creutzfeldt-Jakob disease is caused by prions (A), infectious proteins. Mad cow (B) is a variant but not the sole cause, and viral (C) or fungal (D) causes are incorrect.
The nurse is developing a plan of care for a client diagnosed with aseptic meningitis secondary to a brain tumor. Which nursing goal would be most appropriate for the client problem 'altered cerebral tissue perfusion'?
- A. The client will be able to complete activities of daily living.
- B. The client will be protected from injury if seizure activity occurs.
- C. The client will be afebrile for 48 hours prior to discharge.
- D. The client will have elastic tissue turgor with ready recoil.
Correct Answer: B
Rationale: Altered cerebral perfusion in meningitis may lead to seizures. Protecting from injury during seizures (B) addresses this risk. ADLs (A), fever (C), and tissue turgor (D) are unrelated to perfusion.