A 43-year-old male presents to the emergency department in a stupor accompanied by his wife. She called the ambulance because her husband was difficult to awaken this morning
She reports that for the last 3 days, he has had fever and upper respiratory infection. Yesterday he had a headache. He has had no medical treatment. On physical examination, the patient demonstrates 103 fever, sluggish pupil response, and nuchal rigidity. Which of the following should the clinician attempt to elicit next?
A. Hallpike maneuver
B. Kernig's sign
C. Epley maneuver
D. Babinski's sign
ANS: B
In meningitis fever, photophobia, phonophobia, nausea, vomiting, and nuchal rigidity occur. Patients can rapidly decline to delirium, seizures, and, if untreated, coma. On neurological examination, the patient may be lethargic and febrile and have altered mentation along with nuchal rigidity and/or guarding, contracted and sluggish pupils, and a generally "toxic" appearance. Brudzinski's and Kernig's signs are helpful in assessing potential meningeal conditions (see Box 15.6). Delirium or acute confusion necessitates immediate transfer to an emergency department for treatment, as the patient can rapidly deteriorate to coma.
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The nurse is caring for a client with dysphagia resulting from a stroke. Which of the following is a primary responsibility of the nurse with regard to feeding the client?
A) Inform the client about the kind of food being offered with each mouthful. B) Keep oral and pharyngeal suctioning equipment at the client's bedside. C) Develop a rapport with the client and promote continuity of care. D) Teach the client about the role of nutrition in recovery.
What should the team leader do in planning care for a group of patients?
A) Make sure that each patient on the team receives equal amounts of nursing care B) Begin by considering the needs of the patients who need the greatest amount of or the most specialized care C) Begin by considering the needs of the patients who need the least amount of care D) Ask his or her team members who they feel like taking care of that day
The nurse has just completed the assessment of a client admitted with a gunshot wound to the femoral artery. Which of the following would be considered the priority nursing diagnosis for this client?
1. Ineffective Airway Clearance 2. Excess Fluid Volume 3. Decreased Cardiac Output 4. Ineffective Coping
Cite examples or scenarios where you might decide to assist the incontinent patient in toileting, rather than delegating this task to the UAP
What will be an ideal response?