a nurse is assessing a client who has meningitis which of the following findings should the nurse report to the provider immediately

HESI LPN

Leadership and Management HESI Test Bank

1. A nurse is assessing a client who has meningitis. Which of the following findings should the nurse report to the provider immediately?

A. Generalized rash over trunk
B. Increased temperature
C. Decreased level of consciousness
D. Report of photophobia

Correct answer: C

Rationale: The correct answer is C: Decreased level of consciousness. In a client with meningitis, a decreased level of consciousness is a critical finding that should be reported immediately. This could indicate increased intracranial pressure or neurological deterioration, requiring prompt intervention. Choices A, B, and D are important in the assessment of meningitis but are not as immediately concerning as a decreased level of consciousness. A generalized rash over the trunk can be seen in meningococcal meningitis, an increased temperature is expected due to the inflammatory response, and photophobia is a common symptom due to meningeal irritation.

2. Which manifestation should the nurse expect to assess in a patient with fluid volume deficit?

A. Headache and muscle cramps
B. Dyspnea and respiratory crackles
C. Increased pulse rate and blood pressure
D. Orthostatic hypotension and flat neck veins

Correct answer: D

Rationale: Orthostatic hypotension and flat neck veins are classic manifestations of fluid volume deficit. When the body loses fluid, blood volume decreases, leading to decreased venous return to the heart, resulting in orthostatic hypotension and flat neck veins. Choices A, B, and C are more indicative of other conditions such as dehydration, respiratory issues, or compensatory mechanisms in response to hypovolemia, respectively.

3. What is the primary focus of primary healthcare?

A. Emergency care
B. Preventive care
C. Specialized treatment
D. Hospital-based services

Correct answer: B

Rationale: The correct answer is B: Preventive care. Primary healthcare emphasizes preventive care, which includes promoting overall health, preventing diseases, and providing early intervention to avoid the progression of illnesses. Emergency care (choice A) is focused on immediate medical attention for urgent health situations but is not the primary focus of primary healthcare. Specialized treatment (choice C) refers to care provided by specialists for specific health conditions, which is not the main focus of primary healthcare. Hospital-based services (choice D) involve inpatient care provided in a hospital setting, which is not the primary focus of primary healthcare that aims to provide comprehensive and accessible care at the community level.

4. Which of the following is considered normal for the neonate?

A. Chest Circumference: 10 to 13 inches
B. Length: 16 to 22 inches
C. Weight: 1,500 to 4,000 g
D. Head Circumference: 12.6 to 14.5 inches

Correct answer: D

Rationale: A normal head circumference for a neonate typically falls within the range of 12.6 to 14.5 inches. Choice A is incorrect because the chest circumference for a neonate is usually smaller. Choice B is incorrect as the length of a neonate is typically shorter. Choice C is incorrect as the weight of a neonate is usually measured in grams and falls within a different range.

5. You are performing a neurological assessment of your adolescent patient. The patient has the Moro reflex. How should you interpret this neurological assessment finding?

A. It is normal among adolescents.
B. It indicates that the patient has an intact peripheral nervous system.
C. It indicates that the patient has an intact central nervous system.
D. It is not a normal finding.

Correct answer: D

Rationale: The Moro reflex, also known as the startle reflex, is typically present in infants up to around 4-6 months of age and is characterized by the infant's response to a sudden loss of support or loud noise. It is not a normal finding in adolescents or older individuals. Therefore, if an adolescent patient exhibits the Moro reflex during a neurological assessment, it is considered abnormal and warrants further evaluation. Choices A, B, and C are incorrect because the Moro reflex is not expected or normal among adolescents and does not specifically indicate the status of either the peripheral or central nervous system in this age group.