Questions 74

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NCLEX RN Questions on Neurological Disorders Questions

Extract:

The following scenario applies to the next 6 items
The nurse in the emergency department (ED) is caring for a 20-year-old female client
Item 4 of 6
ED Triage Note
History And Physical
0912: Client was brought to the ED by her two college roommates 'because she was not acting right.' The roommate reports that she went to bed the night before reporting stiffness in her neck and a headache. She attributed it to being under pressure with final exams and having poor sleep the previous several days. The client apparently took non-prescribed lorazepam from another roommate to assist her with sleep. The roommate reported recently having influenza and is unsure if she became infected. It is reported that she declined the influenza vaccination when it was offered on campus. The roommate reports waking her with physical stimuli and found her diaphoretic, hot to touch, and mumbling, saying she did not feel well.
Vital signs: T 103.4° F (39.7° C), P 112, RR 12, BP 116/86, pulse oximetry 95% on room air.


Question 1 of 5

For each potential nursing intervention, click to specify whether the intervention is indicated or not indicated for the care of the client: A= Indicated, B= Not Indicated

Potential InterventionIndicated Not indicated
Keep the door to the client's room closed to maintain negative airflow
Provide visitors with face shields upon entering the client's room
Provide a quiet environment
Perform frequent neurological assessments
Obtain an order to start a peripheral vascular access device
Prepare the client for an immediate electroencephalography (EEG)

Correct Answer: B,B,A,A,A,B

Rationale: Negative airflow is not typically required for bacterial meningitis unless airborne precautions are specified. Face shields are not standard for meningitis; droplet precautions are usually sufficient. A quiet environment reduces stimulation for a client with neurological symptoms. Frequent neurological assessments are critical for monitoring meningitis progression. IV access is necessary for administering antibiotics and fluids in suspected meningitis. EEG is not indicated unless seizures are suspected.

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Question 2 of 5

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Question 3 of 5

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Question 4 of 5

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Question 5 of 5

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Similar Questions

For each client finding below, click to specify if the finding is consistent with the disease process of benzodiazepine toxicity, bacterial meningitis, or influenza:
The emergency department (ED) nurse triages a client with suspected bacterial meningitis. The nurse plans on assessing the client for Kernig's sign. The nurse understands that this sign is positive when the client?
The nurse is preparing a staff in-service regarding sensorineural hearing loss. It would be appropriate for the nurse to identify which factors cause this type of hearing loss?
The nurse is caring for an 82-year-old male client admitted to the hospital for pneumonia. Which of the following findings may indicate a change in mental status?
Select the three (3) prescriptions/orders the nurse should anticipate for this client

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