A nurse in the emergency department is caring for a child who has a temperature of 39.1° C (102.4° F) and a suspected diagnosis of bacterial meningitis.
Which of the following actions should the nurse take first?
Prepare the child for a lumbar puncture.
Dim the lights in the child's room.
Administer an antipyretic to the child.
Implement droplet precautions for the child.
The Correct Answer is D
The correct answer is choice d. Implement droplet precautions for the child.
Choice A rationale:
Preparing the child for a lumbar puncture is important for diagnosing bacterial meningitis, but it is not the first action. Immediate infection control measures are more critical to prevent the spread of the disease.
Choice B rationale:
Dimming the lights can help reduce discomfort from photophobia, a common symptom of meningitis, but it is not the priority action when first addressing a suspected case of bacterial meningitis.
Choice C rationale:
Administering an antipyretic to reduce fever is important for comfort and to manage symptoms, but it does not address the immediate need to prevent the spread of infection.
Choice D rationale:
Implementing droplet precautions is the first action the nurse should take. Bacterial meningitis can be highly contagious, and droplet precautions help prevent the spread of the infection to other patients and healthcare workers.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Providing frequent range of motion to the neck and shoulders is not appropriate for an infant with bacterial meningitis. Meningitis is an inflammation of the membranes surrounding the brain and spinal cord and can cause severe neck pain and stiffness. Range of motion exercises could exacerbate the discomfort and should be avoided.
Choice B rationale:
Keeping the television on in the room to provide background noise is not appropriate for an infant with bacterial meningitis. Infants with meningitis need a quiet and calm environment to reduce stimuli and promote healing.
Choice C rationale:
Padding the side rails of the crib is important to prevent injury during seizures, which can occur in bacterial meningitis. Seizures can cause uncontrolled movements, and padding the crib rails can prevent the infant from getting hurt during these episodes.
Choice D rationale:
Placing the infant in a semiprivate room is not appropriate for bacterial meningitis. Infants with meningitis need isolation to prevent the spread of the infection to other patients. They should be placed in a private room with strict infection control measures in place.
Correct Answer is C
Explanation
Choice A rationale:
Increased heart rate is not a direct indication of the effectiveness of chest physiotherapy treatments in a child with cystic fibrosis. The primary goal of chest physiotherapy is to clear mucus from the airways and improve breathing.
Choice B rationale:
Increased urine output is not directly related to the effectiveness of chest physiotherapy treatments. The focus of chest physiotherapy is on respiratory function and mucus clearance.
Choice C rationale:
Increased expectoration (coughing up mucus) is a positive sign that chest physiotherapy treatments have been effective. Improved clearance of mucus from the airways helps in breathing and reduces the risk of respiratory infections. It indicates that the treatments are helping the child clear the mucus, which is a common problem in cystic fibrosis.
Choice D rationale:
Reduced pain is not the primary goal of chest physiotherapy treatments for cystic fibrosis. While it's essential for the child to be comfortable, the main focus is on improving respiratory function and clearing mucus from the airways.
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