Author Question: When assessing a 53-year-old patient with bacterial meningitis, the nurse obtains the following ... (Read 107 times)

melly21297 · **on:** Jun 25, 2018

When assessing a 53-year-old patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider?

a. The patient exhibits nuchal rigidity.
b. The patient has a positive Kernig's sign.
c. The patient's temperature is 101 F (38.3 C).
d. The patient's blood pressure is 88/42 mm Hg.

Question 2

A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first?

a. Document the BP and ICP in the patient's record.
b. Report the BP and ICP to the health care provider.
c. Elevate the head of the patient's bed to 60 degrees.
d. Continue to monitor the patient's vital signs and ICP.

brittanywood · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: D
Shock is a serious complication of meningitis, and the patient's low blood pressure indicates the need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernig's sign are expected with bacterial meningitis. The nurse should intervene to lower the temperature, but this is not as life threatening as the hypotension.

Answer to Question 2

ANS: B
Calculate the cerebral perfusion pressure (CPP): (CPP = mean arterial pressure MAP ICP). MAP = DBP + 1/3 (systolic blood pressure SBP diastolic blood pressure DBP). Therefore the (MAP) is 70 and the CPP is 56 mm Hg, which is below the normal of 60 to 100 mm Hg and approaching the level of ischemia and neuronal death. Immediate changes in the patient's therapy such as fluid infusion or vasopressor administration are needed to improve the cerebral perfusion pressure. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation will also be done, but they are not the first actions that the nurse should take.