Difficulty: Medium
Average Score: 67%
Simulated
Passage / Scenario
Nurses' NotesClient admitted to the emergency department with a 2-day history of lethargy, nausea, vomiting, anorexia, headache, and general muscle aches. The client reports diarrhea, abdominal pain, and a sore throat. Pupils are 3 mm, equal and reactive to light. Intermittent nystagmus noted. Client reports sensitivity to light.
Client is lethargic, but arouses easily and is oriented to person, place, and time. Hand grasps are strong and equal bilaterally.
Bilateral breath sounds are clear and present throughout. Apical pulse is regular.
Skin is warm and dry. Pinpoint, red, macular rash noted on upper chest. Abdomen is distended, bowel sounds are present in 4 quadrants.
Vital Signs
Temperature 38.9┬░ C (102┬░ F)
Blood pressure 168/80 mm Hg
Heart rate 118/min
Respiratory rate 24/min
Oxygen saturation 95% on room air
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Correct answer
B (Meningitis), A (Seizure precautions, Dim lights), C (Neurologic status, Temperature)
Rationale
Symptoms like headache, photophobia, and rash suggest meningitis, requiring seizure precautions and light reduction, with monitoring of neurologic status and temperature.