NCLEX questions Encephalitis and stuff

Which of the following values is considered normal for ICP? 0 to 15 mm Hg 25 mm Hg 35 to 45 mm Hg 120/80 mm Hg

0 to 15 mmHg

Which of the following symptoms may occur with a phenytoin level of 32 mg/dl? Ataxia and confusion Sodium depletion Tonic-clonic seizure Urinary incontinence

Ataxia and confusion. A therapeutic phenytoin level is 10 to 20 mg/dl. A level of 32 mg/dl indicates toxicity. Symptoms of toxicity include confusion and ataxia. Phenytoin doesn't cause hyponatremia, seizure, or urinary incontinence. Incontinence may occur during or after a seizure.

A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new onset generalized tonic-clonic seizures. Which nursing activities included in the patient's care will be best to delegate to an LPN/LVN whom you are supervising? (Choose all that apply). A Document the onset time, nature of seizure activity, and postictal behaviors for all seizures. B Administer phenytoin (Dilantin) 200 mg PO daily. C Teach patient about the need for good oral hygiene. D Develop a discharge plan, including physician visits and referral to the Epilepsy Foundation.

B

The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising? A Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. B Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. C Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. D Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.

B

Which of the following pathologic processes is often associated with aseptic meningitis? Ischemic infarction of cerebral tissue Childhood diseases of viral causation such as mumps Brain abscesses caused by a variety of pyogenic organisms Cerebral ventricular irritation from a traumatic brain injury

Childhood diseases of viral causation such as mumps

The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate? Select all that apply. Head tilt Vomiting Polydipsia Lethargy Increased appetite Increased pulse

Head tilt, vomiting, lethargy

Which of the following would lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation? Hemorrhagic skin rash Edema Cyanosis Dyspnea on exertion

Hemorrhagic skin rash- DIC is characterized by skin petechiae and a purpuric skin rash caused by spontaneous bleeding into the tissues. An abnormal coagulation phenomenon causes the condition.

A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances? Vomiting continues Intracranial pressure (ICP) is increased The client needs mechanical ventilation Blood is anticipated in the cerebralspinal fluid (CSF)

Intracranial pressure (ICP) is increased

Meningitis occurs as an extension of a variety of bacterial infections due to which of the following conditions? Congenital anatomic abnormality of the meninges Lack of acquired resistance to the various etiologic organisms Occlusion or narrowing of the CSF pathway Natural affinity of the CNS to certain pathogens

Lack of acquired resistance to the various etiologic organisms

When interviewing the parents of a 2-year-old child, a history of which of the following illnesses would lead the nurse to suspect pneumococcal meningitis? Bladder infection Middle ear infection Fractured clavicle Septic arthritis

Middle ear infection

The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain? Sternal rub Pressure on the orbital rim Squeezing the sternocleidomastoid muscle Nail bed pressure

Nail bed pressure

The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure? Side-lying, with legs pulled up and head bent down onto the chest Side-lying, with a pillow under the hip Prone, in a slight Trendelenburg's position Prone, with a pillow under the abdomen.

Side-lying, with legs pulled up and head bent down onto the chest

A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons? To reduce intraocular pressure To prevent acute tubular necrosis To promote osmotic diuresis to decrease ICP To draw water into the vascular system to increase blood pressure

To promote osmotic diuresis to decrease ICP

A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? Urine output increases Pupils are 8 mm and nonreactive Systolic blood pressure remains at 150 mm Hg BUN and creatinine levels return to normal

Urine output increases