Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse takes report on a client who was admitted with a severe heada
che, nausea, vomiting, photophobia, and a stiff neck. Which of the following is the priority intervention for the nurse to perform
?
A. Prepare the client for a MRI
Prepare the client for a MRI. This is not the priority intervention because it does not addressthe possible cause of the client's symptoms, which are suggestive of meningitis, an inflammation of the meninges that can be caused by bacteria or viruses. A MRI may be ordered later to rule out other causes of headache, such as tumor or hemorrhage, but it is not urgent.
B. Monitor for increased intracranial pressure
Monitor for increased intracranial pressure. This is an important intervention, but not the priority one, because it does not treat the underlying infection that may be causing the increased intracranial pressure. The nurse should monitor for signs of increased intracranial pressure, such as changes in level of consciousness, pupil reaction, vital signs, and neurological status, but also administer antibiotics as soon as possible.
C. Administer penicillin
Administer penicillin. This is the priority intervention because it can treat bacterial meningitis, which is a lifethreatening condition that requires immediate antibiotic therapy. The nurse should obtain blood cultures before administering penicillin, but should not delay treatment if cultures are not available.
D. Identify if the client has had a recent respiratory illness
Identify if the client has had a recent respiratory illness. This is not the priority intervention because it does not provide immediate relief or treatment for the client's symptoms or infection. The nurse should ask about recent exposure to respiratory infections, such as influenza or streptococcus, as part of the history taking, but this is not urgent.
This question is an excerpt from Nurse Dive's nursing test bank - Ati med surg adult care 2 proctored exam. Take the full exam now
Similar Questions
A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect?
A. Pruritus
Pruritus is not a manifestation of Parkinson's disease. It is a sensation of itching that can have various causes, such as dry skin, allergies, or infections.
B. Hypertension
Hypertension is not a manifestation of Parkinson's disease. It is a condition of high blood pressure that can increase the risk of cardiovascular complications, such as stroke or heart attack.
C. Bradykinesia
Bradykinesia is a manifestation of Parkinson's disease. It is a term that means slow movement and refers to the difficulty in initiating and performing voluntary actions, such as walking, speaking, or swallowing.
D. Xerostomia
Xerostomia is not a manifestation of Parkinson's disease. It is a term that means dry mouth and can result from dehydration, medication side effects, or salivary gland disorders.
A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased Intracranial pressure (ICP). Which of the following assessment findings by the nurse supports this suspicion?
A. A decrease in the Glasgow Coma Score
Correct. A decrease in the Glasgow Coma Score indicates a deterioration in the level of consciousness, which is a sign of increased ICP.
B. Photophobia
Incorrect. Photophobia is a common symptom of bacterial meningitis, but it does not necessarily indicate increased ICP.
C. Fever
Incorrect. Fever is also a common symptom of bacterial meningitis, but it does not directly affect ICP.
D. Nuchal rigidity
Incorrect. Nuchal rigidity is another common symptom of bacterial meningitis, but it is caused by inflammation of the meninges, not by increased ICP.
A nurse is admitting a young adult client who has suspected bacterial meningitis. The nurse should closely monitor the client for increased intracranial pressure (ICP) as indicated by which of the following findings?
A. Elevated temperature
Incorrect. Elevated temperature is a common symptom of bacterial meningitis, but it does not directly affect ICP.
B. Pupils reactive to light
Incorrect. Pupils reactive to light indicate normal cranial nerve function, which does not necessarily reflect ICP status.
C. Widened pulse pressure
Correct. Widened pulse pressure is the difference between systolic and diastolic blood pressure, which increases as a compensatory mechanism to maintain cerebral perfusion in the face of increased ICP.
D. Nuchal rigidity
Incorrect. Nuchal rigidity is another common symptom of bacterial meningitis, but it is caused by inflammation of the meninges, not by increased ICP.