a nurse is assessing a client who has bacterial meningitis which of the following findings should the nurse expect
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Nursing Elites

ATI RN

ATI Comprehensive Exit Exam

1. A healthcare provider is assessing a client who has bacterial meningitis. Which of the following findings should the healthcare provider expect?

Correct answer: A

Rationale: Nuchal rigidity is a classic sign of bacterial meningitis and indicates inflammation of the meninges. It is characterized by neck stiffness and pain upon neck flexion. Flaccid paralysis (Choice B) is not typically associated with bacterial meningitis but rather conditions like Guillain-Barre syndrome. Bradycardia (Choice C) and hypothermia (Choice D) are not commonly seen in bacterial meningitis; instead, patients may present with fever, tachycardia, and signs of systemic inflammation.

2. A client has a new diagnosis of COPD. Which of the following instructions should the nurse include in the teaching?

Correct answer: B

Rationale: Pursed-lip breathing is a beneficial technique for clients with COPD as it helps control shortness of breath and improves oxygenation. This technique involves inhaling slowly through the nose and exhaling through pursed lips, which helps keep airways open. Option A is incorrect as breathing rapidly through the mouth when using the incentive spirometer can lead to hyperventilation. Option C is incorrect because it is important for clients with COPD to stay hydrated by drinking fluids between meals, but not during meals which can cause bloating and discomfort. Option D is incorrect as diaphragmatic breathing, though beneficial, is not the preferred technique for managing dyspnea in COPD; pursed-lip breathing is more effective.

3. A client has a new diagnosis of hypertension, and a nurse is teaching about dietary management. Which of the following instructions should the nurse include?

Correct answer: A

Rationale: The correct answer is A: Limit your sodium intake to 2,000 mg per day. Limiting sodium intake helps manage hypertension by reducing fluid retention and lowering blood pressure. Choice B is incorrect because increasing intake of high-fat foods can worsen hypertension by contributing to weight gain and other cardiovascular risks. Choice C is incorrect as green, leafy vegetables are beneficial for hypertension due to their high potassium and other nutrient content. Choice D is incorrect as limiting potassium intake is typically not recommended for hypertension management unless specified by a healthcare provider.

4. What is the initial step in managing a suspected pulmonary embolism in a patient?

Correct answer: A

Rationale: Administering oxygen is the initial step in managing a suspected pulmonary embolism. Oxygen therapy is crucial to improve oxygenation levels in the blood when there is a suspected blockage in the pulmonary artery. Administering anticoagulants, although important in the treatment of pulmonary embolism, is not the first step as ensuring adequate oxygen supply takes precedence. Repositioning the patient or administering IV fluids are not the primary interventions for a suspected pulmonary embolism and are not as essential as providing oxygen support.

5. A nurse is administering digoxin 0.125 mg Po to an adult client. For which of the following findings should the nurse report to the provider?

Correct answer: B

Rationale: The correct answer is B. An apical pulse below 60/min indicates bradycardia, a potential sign of digoxin toxicity. The nurse should report this finding to the provider for further evaluation and possible adjustment of the digoxin dose. Choice A, a potassium level of 4.2 mEq/L, is within the normal range (3.5-5.0 mEq/L) and does not indicate toxicity. Choice C, a digoxin level of 1 ng/ml, is within the therapeutic range (0.5-2 ng/ml) and is not suggestive of toxicity. Choice D, constipation for 2 days, is not directly related to digoxin administration and would not require an immediate report to the provider.

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