A nurse in the emergency department (ED) is caring for an adolescent. Exhibits Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again. Nurses' Notes 2 weeks ago, 1000: 16-year-old adolescent is brought to the emergency department (ED) due to a sudden onset of fever, headache, and reports of sensitivity to light. Guardian reports adolescent is refusing to eat or drink due to nausea. Adolescent is lethargic and drowsy, arouses with verbal stimuli, but is irritable when aroused. Pupils equal, round, reactive to light, and accommodation (PERRLA). Hand grasps and pedal pulls and pushes are strong and equal bilaterally. Mucus membranes are dry and pink. Skin is very warm and dry to touch. Capillary refill is 2 seconds. Photophobia is present. Client reports headache pain as 10 on a scale of 0 to 10. Resists flexion of the neck. Cervical lymph nodes are without edema or tenderness. Breath sounds are clear and equal. Abdomen is soft, flat, bowel sounds are heard in all quadrants. Has small pinpoint purpuric rash bilaterally on lower extremities.

Rationale for correct findings: • Sudden onset of fever, headache, and sensitivity to light: These are hallmark symptoms of acute meningitis, where inflammation of the meninges causes severe headache and meningeal irritation. The fever reflects systemic infection, while photophobia results from irritation of the cranial nerves by meningeal inflammation. • Adolescent is lethargic and drowsy, arouses with verbal stimuli, but irritable when aroused: Altered level of consciousness is a critical sign of central nervous system infection. Lethargy and irritability point toward worsening meningeal inflammation and rising ICP, both of which are dangerous and may precede seizures or coma. • Photophobia is present: Photophobia occurs when inflammation of the meninges irritates cranial nerves III and IV, making light uncomfortable for the patient. This neurological sign is highly suggestive of meningitis, especially when combined with headache and fever. • Client reports headache pain as 10/10: Severe headache is a defining symptom of meningitis and a consequence of meningeal irritation and increased ICP. Pain rated at the maximum level indicates intense distress and neurological involvement. • Resists flexion of the neck: Nuchal rigidity is a classic clinical sign of meningeal irritation. Resistance to neck flexion reflects protective muscle spasm caused by inflamed meninges. This, alongside fever and altered mental status, is a key diagnostic triad for meningitis. • Small pinpoint purpuric rash bilaterally on lower extremities: A purpuric rash is an ominous finding, particularly suggestive of meningococcemia, a life-threatening meningococcal infection. The rash indicates vascular damage and possible disseminated intravascular coagulation (DIC), both of which can progress rapidly to septic shock. Rationale for incorrect findings: • Pupils equal, round, reactive to light, and accommodation (PERRLA): This finding indicates that cranial nerves II and III are functioning normally, and there is no immediate sign of increased intracranial pressure compressing the optic nerve. • Hand grasps and pedal pushes and pulls are strong and equal bilaterally: Strong and equal motor responses show that gross motor strength and neurological function in the extremities are intact. No focal weakness or paralysis is evident, meaning there is no localized neurological deficit. • Abdomen is soft, flat, bowel sounds are heard in all quadrants; A soft abdomen with normal bowel sounds indicates intact gastrointestinal motility and no evidence of peritonitis, obstruction, or ileus. Despite nausea, there is no abdominal pathology complicating the case.