The nurse is assessing a client for bacterial meningitis. Which of the following assessments should the nurse perform?
Select all that apply.
The nurse is assessing a client for bacterial meningitis. Which of the following assessments should the nurse perform?
Select all that apply.
Statistics
Subject/Lesson
Subject
Adult Health
Lesson
Infectious Disease
Client Need
Test Plan
Physiological Adaptation
Related Topic
Illness Management
Item Type
Item Type
Analysis
Explanation
Choices A and D are correct. Bacterial meningitis manifests as a stiff neck, photophobia, fever, altered mental status, and malaise. The nurse would need to perform an oral temperature and the Glasgow Coma Scale to discern the client’s current mental status.
Choice B is incorrect. Patellar reflexes are not significant in the assessment of a client with bacterial meningitis. Patellar reflexes would be pertinent for a client with a severe electrolyte imbalance such as hypermagnesemia.
Choice C is incorrect. Weber and Rinne testing is utilized to differentiate between the types of hearing loss and is not pertinent to meningitis.
Choice E is incorrect. A client with meningitis may have low blood pressure due to the dehydration caused by the fever. However, an orthostatic assessment of their blood pressure is not warranted.
Related Videos
4 Key Topics
Glasgow Coma Scale- Critical Care
27.2 Critical Care Neurovascular System
Meningitis
16.5 Central Nervous System Disorders
Additional Info
✓ Symptoms of meningitis classically have an abrupt onset and include headache, fever, nuchal rigidity, photophobia, and myalgias.
✓ The nurse's immediate concern is protecting the safety of the staff and the other clients by isolating the client with droplet precautions.
✓ Close monitoring of the client's neurological status and prompt administration of prescribed antibiotics after the lumbar puncture are priorities.
✓ The Glasgow Coma Scale is a quick and effective tool that monitors neurological status.
✓ The highest score on the GCS is 15, which measures the client's best eye-opening, verbal, and motor responses.
Source: Archer Review
https://app.archerreview.com/test-screen/MjQzMzczNDk=/MTE0NTc=
