NUR 436 Exam 2 Questions With Correct
Answers
Bacterial Meningitis - CORRECT ANSWER✔✔-Patho: acute inflammation of meninges; bacteria
causes inflammation and exudate to accumulate in the SUBARACHNOID space leading to
obstruction of CSF flow and increased ICP
CM: seizures, pain, infants (HIGH-PITCHED CRY, BULGING FONTANEL), children >2yrs (change in
mental status, NUCHAL RIGIDITY, POSITIVE KERNIG AND BRUDZINSKI SIGNS, photophobia), fever
Diagnostics: LP of CSF- appears cloudy with high WBC, HIGH PROTEIN, LOW GLUCOSE, gram
stain and culture will identify organism
Nursing dx: risk for infection, decreased cerebral adaptivity, risk for injury (seizures)
Nursing care: s/sx of infection, monitor Na/urine, assess neuro status/seizures, elevated HOB
with head midline, cluster care to decrease stimuli, seizure precautions; monitor pain, comfort
measures, cool bath
Therapeutic management: droplet precautions for 24 hours, corticosteroid (dexamethasone) to
decrease inflammation, seizures- antiepileptics, cerebral edema tx
Quality outcomes: early recognition of s/sx, abx administered as soon as dx is established,
cerebral edema prevented, exposure prevented by early isolation, SE managed, neurologic
sequalae prevented
Viral Encephalitis - CORRECT ANSWER✔✔-Patho: acute inflammatory process of the brain
CM: poor feeding and anorexia, headache, NUCHAL RIGIDITY, tremors, ataxia, speech
difficulties, severe cases (increased ICP, decreased LOC, seizures, ocular palsies, paralysis
Diagnostics: CT/MRI, LP
Nursing dx: risk for infection, decreased cerebral adaptivity, risk for injury (seizures), IMPAIRED
MOBILITY
, Nursing care: s/sx of infection, monitor seizures, pain, assess neuro, elevated HOB with head
midline, cluster care to decrease stimuli, seizure precautions, ASSESS FALL RISK, MOBILITY ,
BRADEN Q, ALTERNATE COMMUNICATION MEANS, TURN Q2HR
Therapeutic management: IV/NG feeds and hydration, ANTIVIRAL AGENT (HERPES SIMPLEX
ONLY), prevent long term disabilities, PT/OT/speech
Quality outcomes: early recognition and s/sx of meningitis, cerebral edema prevented, SE
managed, neurologic sequalae prevented
Reye Syndrome - CORRECT ANSWER✔✔-Patho: acute METABOLIC ENCEPHALOPATHY D/T
MITOCHONDRIAL DYSFUNCTION -> FATTY ACID METABOLISM DISTURBANCES -> FATTY LIVER
(DYSFUNCTION) -> CEREBRAL EDEMA
CM: fever, PROFUSE VOMITING, profound impaired consciousness with pathological cerebral
edema
Diagnostics: CT, hepatic lab levels (increased PT, PTT, AST, ALT, NH4), palpable hepatomegaly,
liver biopsy performed
Nursing dx: impaired comfort/fluid volume deficit, decreased cerebral adaptivity, risk for injury
(seizures), RISK FOR INJURY (BLEEDING)
Nursing care: monitor temp/VS, I&O, seizures, assess neuro, elevated HOB with head midline,
seizure precautions, cluster care, MONITOR FOR S/SX OF BLEEDING, BLEEDING PRECAUTIONS
(NO RECTAL TEMSP, ENEMAS, NO IM MEDS), USE TOOTHETTES
Therapeutic management: antipyretic/antiemetic- IVF PRN, prevent long term
disabilities ,seizure meds, cerebral edema tx, NO NSAIDS, monitor hepatic lab levels
Spina Bifida Occulta - CORRECT ANSWER✔✔-Midline defect involving failure of the osseous
spine to close, but not visible externally
Meningocele - CORRECT ANSWER✔✔-Hernial protrusion of a saclike cyst of meninges filled with
spinal fluid
Anecephaly - CORRECT ANSWER✔✔-Absence of cerebral hemisphere, incompatible with life
Answers
Bacterial Meningitis - CORRECT ANSWER✔✔-Patho: acute inflammation of meninges; bacteria
causes inflammation and exudate to accumulate in the SUBARACHNOID space leading to
obstruction of CSF flow and increased ICP
CM: seizures, pain, infants (HIGH-PITCHED CRY, BULGING FONTANEL), children >2yrs (change in
mental status, NUCHAL RIGIDITY, POSITIVE KERNIG AND BRUDZINSKI SIGNS, photophobia), fever
Diagnostics: LP of CSF- appears cloudy with high WBC, HIGH PROTEIN, LOW GLUCOSE, gram
stain and culture will identify organism
Nursing dx: risk for infection, decreased cerebral adaptivity, risk for injury (seizures)
Nursing care: s/sx of infection, monitor Na/urine, assess neuro status/seizures, elevated HOB
with head midline, cluster care to decrease stimuli, seizure precautions; monitor pain, comfort
measures, cool bath
Therapeutic management: droplet precautions for 24 hours, corticosteroid (dexamethasone) to
decrease inflammation, seizures- antiepileptics, cerebral edema tx
Quality outcomes: early recognition of s/sx, abx administered as soon as dx is established,
cerebral edema prevented, exposure prevented by early isolation, SE managed, neurologic
sequalae prevented
Viral Encephalitis - CORRECT ANSWER✔✔-Patho: acute inflammatory process of the brain
CM: poor feeding and anorexia, headache, NUCHAL RIGIDITY, tremors, ataxia, speech
difficulties, severe cases (increased ICP, decreased LOC, seizures, ocular palsies, paralysis
Diagnostics: CT/MRI, LP
Nursing dx: risk for infection, decreased cerebral adaptivity, risk for injury (seizures), IMPAIRED
MOBILITY
, Nursing care: s/sx of infection, monitor seizures, pain, assess neuro, elevated HOB with head
midline, cluster care to decrease stimuli, seizure precautions, ASSESS FALL RISK, MOBILITY ,
BRADEN Q, ALTERNATE COMMUNICATION MEANS, TURN Q2HR
Therapeutic management: IV/NG feeds and hydration, ANTIVIRAL AGENT (HERPES SIMPLEX
ONLY), prevent long term disabilities, PT/OT/speech
Quality outcomes: early recognition and s/sx of meningitis, cerebral edema prevented, SE
managed, neurologic sequalae prevented
Reye Syndrome - CORRECT ANSWER✔✔-Patho: acute METABOLIC ENCEPHALOPATHY D/T
MITOCHONDRIAL DYSFUNCTION -> FATTY ACID METABOLISM DISTURBANCES -> FATTY LIVER
(DYSFUNCTION) -> CEREBRAL EDEMA
CM: fever, PROFUSE VOMITING, profound impaired consciousness with pathological cerebral
edema
Diagnostics: CT, hepatic lab levels (increased PT, PTT, AST, ALT, NH4), palpable hepatomegaly,
liver biopsy performed
Nursing dx: impaired comfort/fluid volume deficit, decreased cerebral adaptivity, risk for injury
(seizures), RISK FOR INJURY (BLEEDING)
Nursing care: monitor temp/VS, I&O, seizures, assess neuro, elevated HOB with head midline,
seizure precautions, cluster care, MONITOR FOR S/SX OF BLEEDING, BLEEDING PRECAUTIONS
(NO RECTAL TEMSP, ENEMAS, NO IM MEDS), USE TOOTHETTES
Therapeutic management: antipyretic/antiemetic- IVF PRN, prevent long term
disabilities ,seizure meds, cerebral edema tx, NO NSAIDS, monitor hepatic lab levels
Spina Bifida Occulta - CORRECT ANSWER✔✔-Midline defect involving failure of the osseous
spine to close, but not visible externally
Meningocele - CORRECT ANSWER✔✔-Hernial protrusion of a saclike cyst of meninges filled with
spinal fluid
Anecephaly - CORRECT ANSWER✔✔-Absence of cerebral hemisphere, incompatible with life
