A nurse is admitting a child who has bacterial meningitis.
Which of the following actions should the nurse take first?
Initiate antibiotic therapy for the child.
Minimize the child's environmental stimuli.
Place the child in a side-lying position.
Administer pain medication to the child.
The Correct Answer is B
Choice A rationale
Initiating antibiotic therapy is a crucial intervention for bacterial meningitis to combat the infection and prevent complications. However, it's not the absolute first action. The immediate priority is to address the child's neurological status and reduce intracranial pressure, which is exacerbated by environmental stimuli. Antibiotics are administered shortly after obtaining blood cultures.
Choice B rationale
Minimizing environmental stimuli is the first priority to reduce the risk of seizures and decrease intracranial pressure. The inflammation of the meninges makes the brain more susceptible to overstimulation, which can trigger seizures. Reducing light, noise, and other stimuli creates a calm environment, which is vital for stabilizing the child's neurological status before other treatments are initiated.
Choice C rationale
Placing the child in a side-lying position is a helpful intervention to prevent aspiration and improve comfort. However, this is not the initial priority. The first action must address the immediate neurological risk posed by increased intracranial pressure and seizure potential, which is achieved by minimizing environmental stimuli.
Choice D rationale
Administering pain medication is important for the child’s comfort and to reduce the stress response. However, it is a secondary intervention. The primary action is to ensure the child's safety by mitigating neurological risks, which involves reducing environmental stimuli to prevent seizures and further increases in intracranial pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Honoring a child’s request during a breath-holding spell can reinforce this behavior as an effective manipulative tool, increasing the likelihood of future tantrums. Breath-holding is a physiological response, not a conscious choice, and the child will automatically resume breathing once carbon dioxide levels rise. Giving in validates the behavior and undermines the parent’s authority.
Choice B rationale
A structured daily routine provides a sense of predictability and security for a toddler, reducing anxiety and frustration that often trigger tantrums. When a child knows what to expect, they feel more in control and are less likely to become overwhelmed by changes or transitions, which can be a major source of behavioral outbursts.
Choice C rationale
Isolating a toddler alone in their room during a tantrum can be frightening and may escalate the behavior. The child may interpret this as punishment or abandonment, which can worsen their distress. While a brief "time-out" in a safe, non-stimulating area can be used, leaving them alone until the tantrum ends is often counterproductive and doesn't teach them coping skills.
Choice D rationale
Comforting a child during a temper tantrum can inadvertently reinforce the negative behavior by providing positive attention for an undesirable act. While it is important to provide comfort after the tantrum has subsided, giving attention and soothing words during the outburst can make the child more likely to use tantrums to gain parental attention in the future.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Explanation
Choice A rationale
A rectal biopsy is a definitive diagnostic tool for conditions like Hirschsprung's disease, which presents similarly to the clinical scenario implied. However, administering oral laxatives may not be appropriate in this context, as it could exacerbate symptoms or be contraindicated depending on the specific underlying pathology of the infant's digestive system. The choice of intervention must align with the specific disease process.
Choice B rationale
A pyloromyotomy is the surgical procedure of choice for pyloric stenosis, a condition in which the pyloric sphincter is hypertrophied, obstructing gastric emptying. A hallmark symptom is projectile vomiting, which leads to malnutrition and dehydration. Consequently, measuring abdominal circumference frequently is a crucial nursing intervention to monitor for abdominal distention or changes related to the infant's condition and to assess for potential complications post-operatively.
Choice C rationale
A radiologist-guided gas enema, also known as a therapeutic air enema, is a common non-surgical treatment for intussusception, which is the telescoping of a bowel segment into another. This procedure utilizes air pressure to reduce the intussusception. Transporting the client is a generic nursing action and not a specific, focused intervention directly related to the procedure's scientific principles or the infant's immediate care needs.
Choice D rationale
A rectal biopsy is used to confirm the diagnosis of Hirschsprung's disease by detecting the absence of ganglion cells in the distal colon. However, explaining the purpose of the procedure to an infant is developmentally inappropriate, as infants lack the cognitive ability to comprehend such information. The explanation should be directed to the parents or legal guardians, not the infant themselves.
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