A nurse is caring for a 20-year-old male client who has a fever and reports severe headache.Vital Signs at 0800Temperature 38.9° C (102° F); TympanicApical pulse 118/min; strong and regularRespirations 20/min; even and unlabored Blood pressure 114/78 mm Hg Oxygen saturation 97% on room airNurses Notes0800:Client reports missing classes at a local community college the last two days due to fever and headache. Rates pain with headache as a 9 on a scale of 0 to 10. Verbalizes that headache was not relieved by acetaminophen or ibuprofen taken at home. Client awake, alert, and oriented to person, place, and time. Pupils equal, round, and reactive to light. Temperature elevated.  Skin warm and dry, face flushed.  Petechiae noted on trunk.  Reports nausea and vomiting frequent for the last 24 hr. Bowel sounds positive x 4 quadrants. Abdomen soft and nontender to light palpation. Photophobia present.  Nuchal rigidity noted.  Brudzinski’s sign positive. Respirations easy and unlabored.  Lungs clear to auscultation.   0830:  Provider notified of client’s current vital signs and assessment findings. New prescriptions received. Providers Prescription: Prepare for lumbar puncture  Draw CBC with differential X-ray: Chest and sinuses 1000 Vital Signs Temperature 38.9° C (102° F); Tympanic Apical pulse 50/min; strong and regular Respirations 10/min; even and unlabored  Blood pressure 190/105 mm Hg  Oxygen saturation 97% on room air 1000 Nurses notes: Assessment completed after lumbar puncture. Client awake, restless, confused, and oriented to person only. Pupils equal, round, and reactive to light. Temperature elevated.  Skin warm and dry, face flushed.  Petechiae noted on trunk. Decerebrate posturing noted. Occasional vomiting. Bowel sounds positive x 4 quadrants. Abdomen soft and nontender to light palpation. Photophobia present.  Nuchal rigidity noted.  Brudzinski’s sign positive. Respirations easy and unlabored.  Lungs clear to auscultation.     For each assessment finding, click to specify if the finding indicates that the client’s condition has improved, has not changed, or has declined. 

The nurse is reinforcing teaching with a newly diagnosed patient with amyotrophic lateral sclerosis (ALS).  Which statement would be appropriate to include in the teaching plan?

The nurse is preparing to administer edrophonium chloride (Tensilon) to test a client. Before this drug is administered the nurse will request which antidote be available?

A client with meningitis is receiving Mannitol (Osmitrol). The client receiving this drug should be evaluated for which of the following reactions that would prove the effectiveness of this drug? Select ALL that apply

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Which is the best teaching for the client that has generalized tonic-clonic seizures? 

The nurse is caring for a client admitted to the hospital with bacterial meningitis that developed after an untreated case of otitis media. What evaluation alerts the nurse to changes in the client’s intracranial pressure?

The client has been diagnosed with Guillain Barre´ Syndrome. What assessment would indicate the client is having clinical manifestations of this disease process?

The nurse is assessing the client with a head injury, for level of consciousness utilizing the Glasgow coma scale. The client received a score of 15. Which assessment data contributed to the client’s score? Select ALL that apply

A client with meningitis is receiving Mannitol (Osmitrol). The client receiving this drug should be evaluated for which of the following reactions that would prove the effectiveness of this drug? Select ALL that apply