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

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?

A. Nuchal rigidity.
B. Flaccid paralysis.
C. Bradycardia.
D. Hypothermia.

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. What is the best intervention for a patient with constipation?

A. Administer a stool softener
B. Encourage fluid intake
C. Provide a high-fiber diet
D. Administer a laxative

Correct answer: B

Rationale: Encouraging fluid intake is the best intervention for a patient with constipation. Fluids help soften stools, making them easier to pass. While stool softeners and laxatives can also help with constipation, they are more of a short-term solution and may not address the root cause. A high-fiber diet is beneficial for preventing constipation in the long run, but in the immediate situation of constipation, fluid intake is key.

3. A client with schizophrenia is experiencing delusions. Which of the following interventions should the nurse implement?

A. Tell the client that their delusions are not real
B. Encourage the client to explore the meaning behind their delusions
C. Focus on the client's feelings rather than the delusions
D. Challenge the client's delusions directly

Correct answer: C

Rationale: In caring for a client with schizophrenia experiencing delusions, it is essential to focus on the client's feelings rather than directly addressing or challenging the delusions. By focusing on the client's emotions, the nurse can build trust and rapport without reinforcing the delusions. Choice A is incorrect because directly telling the client that their delusions are not real may lead to confrontation or mistrust. Choice B is incorrect as encouraging exploration of the delusions may further validate them. Choice D is incorrect because challenging the client's delusions can escalate the situation and damage the therapeutic relationship.

4. A healthcare professional is preparing to administer digoxin to a client with heart failure. Which of the following laboratory values should the professional report to the provider?

A. Potassium 4.0 mEq/L
B. Calcium 9.5 mg/dL
C. Sodium 140 mEq/L
D. Magnesium 2.0 mg/dL

Correct answer: C

Rationale: The correct answer is C: Sodium 140 mEq/L. An elevated sodium level can affect the effectiveness of digoxin therapy and may lead to toxicity. Therefore, it is crucial to report this value to the provider. Potassium, calcium, and magnesium levels are important as well, but elevated sodium can have a more direct impact on digoxin therapy in this scenario.

5. What is the first action to take when a patient experiences a seizure?

A. Protect the patient from injury
B. Administer oxygen
C. Administer IV fluids
D. Administer anti-seizure medication

Correct answer: A

Rationale: The first action to take when a patient experiences a seizure is to protect the patient from injury. This is crucial to prevent harm during the seizure. Administering oxygen, IV fluids, or anti-seizure medication may be necessary based on the patient's condition, but ensuring their safety by removing harmful objects, cushioning their head, and keeping the area clear is the immediate priority. Administering oxygen, IV fluids, or medication would come after ensuring the patient's safety.