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

ATI LPN

LPN Fundamentals of Nursing

1. A client with meningitis is being assessed by a healthcare provider. Which of the following findings should the provider expect?

Correct answer: C

Rationale: A petechial rash is a characteristic finding in clients with meningitis, indicating small, pinpoint hemorrhages under the skin. This rash results from the infection's impact on the blood vessels. Petechiae are important to recognize as they can help differentiate meningitis from other conditions with similar symptoms. Brudzinski’s sign, neck stiffness, and positive Kernig’s sign are more common physical exam findings in meningitis. Flaccid neck muscles and hypoactive deep tendon reflexes are not typically associated with meningitis.

2. A nurse is planning discharge teaching for cord care for the parent of a newborn. Which instructions would you include in the teaching?

Correct answer: C

Rationale: The correct instruction to include in the teaching for cord care is to keep the cord dry until it falls off naturally. This helps prevent infection, as the cord typically falls off in 10-14 days, not within five days. Instructing the parent to contact the provider if the cord turns black (Choice A) is important to monitor for signs of infection. Cleaning the base of the cord with hydrogen peroxide daily (Choice B) is not recommended as it can delay healing. Stating that the cord stump will fall off in ten days (Choice D) provides a more accurate timeframe compared to the initial estimation of five days.

3. A client is being discharged after childbirth. At 4 weeks postpartum, the client should contact the provider for which of the following client findings?

Correct answer: C

Rationale: Sore nipples with cracks and fissures should be reported to the provider as this can indicate improper breastfeeding techniques or infection, which requires medical evaluation and intervention to prevent further complications such as mastitis or decreased milk supply. Scant, non-odorous white vaginal discharge is a normal finding postpartum. Uterine cramping during breastfeeding is also common due to oxytocin release. Decreased response with sexual activity may be expected at 4 weeks postpartum due to hormonal changes and fatigue, but it is not typically a concern that needs immediate medical attention.

4. A healthcare professional is assessing a client with severe dehydration. Which finding indicates a need for immediate intervention?

Correct answer: C

Rationale: A urine output of 20 ml/hour indicates severe dehydration and impaired renal function. This finding suggests a critical state where the kidneys are conserving water, leading to reduced urine output. Immediate intervention is required to restore fluid balance and prevent further complications associated with severe dehydration. Choice A, a heart rate of 110 beats per minute, may indicate dehydration but is not as severe as the critically low urine output. Choice B, a blood pressure of 90/60 mm Hg, can be seen in dehydration but is not as concerning as the extremely low urine output. Choice D, dry mucous membranes, is a common sign of dehydration but does not require immediate intervention compared to the severely reduced urine output.

5. How does a nursing infant receive antibodies from its mother?

Correct answer: B

Rationale: A nursing infant receives antibodies from its mother through the absorption of antibodies present in breast milk. Choice A is incorrect as anabolism and catabolism refer to metabolic processes, not the transfer of antibodies. Choice C is incorrect as the infant does not need to synthesize antibodies but directly receives them. Choice D is incorrect because while genetic inheritance plays a role in the immune system, in this case, the direct transfer of antibodies occurs through breast milk.

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