A 2-year-old child with a ventricular shunt has a temperature of 101.5°F (38.6°C), is irritable, and has a heart rate of 160 bpm.

Which of the following is the priority nursing action?

Choice A rationale

Decreased urine output (oliguria, typically <1 mL/kg/hour in a child) is a sign of poor renal perfusion due to reduced cardiac output and is characteristic of later, decompensated shock. In early, compensated septic shock, systemic vascular resistance (SVR) is often reduced (warm shock), and the compensatory mechanisms may still maintain adequate renal blood flow and normal urine output.

Choice B rationale

Cool extremities result from intense peripheral vasoconstriction as a compensatory mechanism to shunt blood to vital organs. This is characteristic of hypovolemic or cold septic shock (high SVR). However, in the more common early warm septic shock in children, peripheral vasodilation (low SVR) leads to flushed, warm extremities, not cool ones.

Choice C rationale

Normal blood pressure (BP) (systolic BP within the normal range, which varies by age, e.g., >90 mmHg in a school-aged child) is the hallmark of compensated shock. Compensatory mechanisms, primarily tachycardia and mild vasoconstriction, are successfully maintaining cardiac output and thus adequate mean arterial pressure, despite underlying circulatory dysfunction.

Choice D rationale

Tachycardia (elevated heart rate, normal range varies by age, e.g., >130 bpm in a toddler) is one of the earliest and most reliable signs of all forms of shock in children. It represents a critical cardiovascular compensatory mechanism to increase cardiac output (Cardiac Output = Stroke Volume×Heart Rate) in response to systemic vasodilation and early hypovolemia characteristic of sepsis.

Choice A rationale

Restricting fluids is generally contraindicated in meningitis unless there is documented syndrome of inappropriate antidiuretic hormone (SIADH) or severe, life-threatening cerebral edema. Maintaining adequate hydration is crucial to prevent dehydration and support systemic circulation, especially since fever can increase fluid loss.

Choice B rationale

Monitoring for signs of increased intracranial pressure (ICP) is paramount because meningeal inflammation can lead to cerebral edema and impaired CSF reabsorption. Signs like changes in level of consciousness, bradycardia, and hypertension (Cushing's triad) require immediate intervention to prevent brain herniation.

Choice C rationale

Administering acetaminophen (or ibuprofen) is appropriate for controlling the systemic symptoms of fever (pyrexia) and managing headache/body pain associated with meningeal irritation. Effective fever control reduces metabolic demands and can decrease the risk of febrile seizures.

Choice D rationale

Administering IV antibiotics immediately is the standard for bacterial meningitis to prevent morbidity and mortality, but viral meningitis is typically self-limiting and managed with supportive care; thus, empirical antibiotics are not indicated if the viral etiology is confirmed or highly suspected.

Choice E rationale

Encouraging rest and hydration is the cornerstone of supportive care for viral meningitis. Rest reduces cerebral metabolic demand and prevents overexertion, while hydration helps combat fluid losses from fever and vomiting and supports overall recovery.

Choice F rationale

Providing a quiet, dimly lit environment helps reduce noxious stimuli that can exacerbate common symptoms like headache and photophobia (light sensitivity), which are caused by meningeal inflammation and irritation of cranial nerves, thus promoting comfort and rest.