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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Avoiding vigorous activity immediately after feeding is not directly related to managing gastroesophageal reflux. The rationale behind this is that keeping the infant upright after feeding helps prevent stomach contents from flowing back into the esophagus. Gravity can help reduce reflux symptoms. Vigorous activities do not impact reflux directly.
Choice B rationale:
Holding the infant in an upright position for 30 minutes after feeding is the correct choice. This position utilizes gravity to keep stomach contents down and prevents reflux. It allows time for the food to move from the stomach to the small intestine, reducing the likelihood of reflux. This intervention is widely recommended for infants with gastroesophageal reflux.
Choice C rationale:
Enlarging the bottle's nipple opening when using thickened feedings is not a recommended practice. Thickened feedings can help reduce reflux, but changing the nipple opening size is not necessary for managing reflux symptoms. The thickness of the feeding itself can help prevent regurgitation.
Choice D rationale:
Propping the bottle during feedings is not recommended. It can lead to aspiration, where the milk can enter the infant's airways, causing respiratory issues. It's essential for the infant to be held in an upright position during feedings to prevent reflux symptoms effectively.
Choice E rationale:
Feeding the infant in a side-lying position is not recommended for infants with gastroesophageal reflux. This position can increase the risk of regurgitation and aspiration. Keeping the infant upright, as mentioned in choice B, is the preferred position to minimize reflux symptoms.
Correct Answer is B
Explanation
Choice A rationale:
Asking the parent if they are willing to take new parenting classes is a closed-ended question that does not encourage open communication or exploration of the parent's coping mechanisms. It does not assess the parent's current strategies or provide an opportunity for them to express their concerns.
Choice B rationale:
Asking the parent what they do when their infant is fussy encourages open dialogue and allows the parent to share their coping mechanisms. It provides insight into the parent's current strategies for managing their infant's fussiness, which can guide the nurse in providing appropriate support and education.
Choice C rationale:
Asking if parenting is overwhelming on a bad day is a general question that may not yield specific information about the parent's coping mechanisms. It does not address the parent's strategies for managing their infant's fussiness or provide a clear understanding of their coping skills.
Choice D rationale:
Asking if parenting causes stress is a closed-ended question that may yield a yes or no response without exploring the parent's coping mechanisms in detail. It does not encourage the parent to elaborate on their experiences or provide specific information about their coping strategies.
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