the nurse is assessing a client with suspected meningitis which finding is indicative of meningeal irritation
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Nursing Elites

ATI LPN

ATI PN Adult Medical Surgical 2019

1. When assessing a client with suspected meningitis, which finding is indicative of meningeal irritation?

Correct answer: D

Rationale: Both Brudzinski's sign and Kernig's sign are classic signs of meningeal irritation, commonly associated with meningitis. Brudzinski's sign is positive when flexing the neck causes involuntary flexion of the hips and knees due to irritation of the meninges. Kernig's sign is positive when there is pain and resistance with knee extension after hip flexion, indicating meningeal irritation or inflammation. The Babinski reflex, mentioned in choice B, is a test used to assess upper motor neuron damage and is not specific to meningitis. Therefore, choices A and C are the correct options as they are indicative of meningeal irritation in a suspected case of meningitis.

2. A patient with chronic heart failure is prescribed carvedilol. What is the primary purpose of this medication?

Correct answer: C

Rationale: Carvedilol, a beta-blocker, is primarily prescribed in patients with chronic heart failure to decrease heart rate and reduce the workload on the heart. By lowering the heart rate, carvedilol helps the heart function more efficiently and improves symptoms in patients with heart failure.

3. A client with a newly created ileostomy has not had ostomy output for the past 12 hours and reports worsening nausea. What is the nurse's priority action?

Correct answer: B

Rationale: The nurse's priority action in this situation is to report signs and symptoms of possible obstruction to the healthcare provider. Lack of ostomy output and worsening nausea can indicate a potential obstruction, which requires immediate attention and intervention to prevent complications.

4. When covering another nurse's assignment during a lunch break, based on the status report provided, which client should the charge nurse check first?

Correct answer: D

Rationale: The client with a pneumothorax and a pulse oximeter reading of 90% indicates potential respiratory compromise, requiring immediate attention to prevent further deterioration.

5. A client with a history of diabetes mellitus is admitted with a foot ulcer. The nurse should recognize that which intervention is most critical in promoting healing of the foot ulcer?

Correct answer: A

Rationale: In diabetic clients with foot ulcers, strict control of blood glucose levels is essential for promoting wound healing. High blood glucose levels can impair circulation and compromise the body's ability to fight infection, delaying the healing process. By maintaining optimal blood glucose levels, the client's overall health and wound healing potential are improved.

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