NURS 126 Cerebral

NURS 126 Cerebral Question 1: A seven year old has just been admitted to the unit for excessive vomiting. Based on the available chart data, what is the nurse’s most appropriate action? 10/15/16 0730 Vital Signs Record T: 104.9° F (40.5° C) P: 98 RR: 30 Lab Values Serum Potassium: 3.1 mmol/L Serum Sodium: 128 mmol/L Nurse’s Note Skin flushed and warm to touch; good turgor; petechiae noted over entire trunk a) Cover the petechiae with dry sterile dressings b) Suspect that the child has been abused c) Initiate extremity restraints as seizure precautions d) Assess the child’s neurological status You selected:Assess the child’s neurological status Correct Explanation: Since fever, seizures, vomiting, and petechiae are signs of meningitis, the nurse should promptly assess the child’s neurological status and report the findings to the provider. ... (more) Question 2: A 3-month-old infant with meningococcal meningitis has just been admitted to the pediatric unit. Which nursing intervention has the highest priority? a) obtaining history information from the parents b) instituting droplet precautions c) orienting the parents to the pediatric unit d) administering acetaminophen Correct response: instituting droplet precautions Explanation: Instituting droplet precautions is the priority for a newly admitted infant with meningococcal meningitis. Acetaminophen may be ordered, but administering it does not take priority ... (more) Question 3: A child with meningitis is to receive 1,000 mL of dextrose 5% in normal saline over 12 hours. At what rate in milliliters per hour should the nurse set the pump? Round your answer to the nearest whole number. You selected:83 Correct Explanation: 1,000 mL/12 hours = 83 mL/hour Question 4: A 7-year-old has been diagnosed with bacterial meningitis. Who should receive chemoprophylaxis? a) household contacts only b) all children at the school c) all household contacts and close contacts d) the entire community You selected:all household contacts and close contacts Correct Explanation: Chemoprophylaxis should be given to household contacts and close contacts only. To prevent community outbreaks, chemoprophylaxis with rifampin 600 mg twice a day for 2 days or a si Question 5: A client admitted with bacterial meningitis must be transported to the radiology department for a repeat computed tomography scan of the head. His level of consciousness is decreased, and he requires nasopharyngeal suctioning before transport. Which infection control measures are best when caring for this client? a) Put on gloves, a mask, and eye protection during suctioning, and then apply a mask to the client's face for transport. b) Take no special precautions for this client. c) Put on gloves, a mask, and eye protection. d) Use standard precautions, which require gloves for suctioning. You selected:Put on gloves, a mask, and eye protection during suctioning, and then apply a mask to the client's face for transport. Correct Explanation: Bacterial meningitis is spread through contact with infected droplets. The nurse should wear gloves, a mask, and eye protection when suctioning the client. Additionally, the client ... (more) Question 6: A child with meningococcal meningitis is being admitted to the pediatric unit. In preparation for the child's arrival, the nurse should first? a) institute droplet precautions. b) inquire about the health of siblings at home. c) ask the parent about medication allergies. d) obtain the child's vital signs. You selected:institute droplet precautions. Correct Explanation: The child with meningococcal meningitis requires droplet precautions for at least the first 24 hours after effective therapy is initiated to reduce the risk of transmission to othe ... (more) Question 7: 2/10/2017 2100 18-year-old college student presents to the emergency department with a severe headache and onset of bizarre behavior that started approximately five hours ago. Client is oriented to person, but not place or time. Physical assessment includes petechiae. Oral temperature is 104° F (40° C). HR: 128/bpm. RR: 24/min, O2: 95% on room air. Lumbar puncture ordered. Client is being evaluated for bacterial meningitis. What is the most important action by the nurse? a) Administer an analgesic per order b) Prepare this client for endotracheal intubation c) Obtaining IV access in preparation of antibiotic administration d) Administer the meningitis vaccination per order Correct response: Obtaining IV access in preparation of antibiotic administration Explanation: This client’s rapid course, and petechiae suggest that she is at risk for a fulminant presentation of meningitis, which can include circulatory collapse. Intravenous access may b ... (more) Question 8: A preschool-age child has just been admitted to the pediatric unit with a diagnosis of bacterial meningitis. What is the nurse’s priority intervention? a) Decrease environmental stimulation b) Monitor temperature every four hours c) Assess LOC every 12 hours d) Encourage the parents to hold the child Correct respons Decrease environmental stimulation Explanation: A child with the diagnosis of meningitis is more comfortable in an environment with decreased stimuli. Noise and bright lights would stimulate this child and cause the child to cry ... (more) Question 9: A 6-year-old child has tested positive for West Nile virus infection. The nurse suspects the child has the severe form of the disease when she recognizes which signs and symptoms? a) Fever, lymphadenopathy, and rash b) Anorexia, nausea, and vomiting c) Fever, muscle weakness, and change in mental status d) Fever, rash, and malaise You selected:Fever, muscle weakness, and change in mental status Correc Explanation: Severe West Nile virus infection (also called West Nile encephalitis or West Nile meningitis) affects the central nervous system and may cause headache, neck stiffness, fever, musc ... (more) Question 10: Which sign should lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation? a) hemorrhagic skin rash b) edema c) cyanosis d) dyspnea on exertion You selected:hemorrhagic skin rash Correct Explanation: Disseminated intravascular coagulation is characterized by skin petechiae and a purpuric skin rash caused by spontaneous bleeding into the tissues. An abnormal coagulation phenomen ... (more)