A nurse is assessing a client who was brought into the emergency room following a seizure. The nurse suspects the client may have meningococcal meningitis when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate next?

Administer an antipyretic.

Complete a vascular assessment.

Assess the cranial nerves.

Decrease environmental stimuli.

Answer and Explanation

The Correct Answer is C

Choice A reason:

Administering an antipyretic can help reduce fever, which is a common symptom of meningococcal meningitis. However, this action does not address the immediate need to assess the extent of neurological impairment. While fever management is important, it is not the first priority in this situation.

Choice B reason:

Completing a vascular assessment is important to evaluate the client’s circulatory status, especially if there are signs of septicemia. However, in the context of suspected meningococcal meningitis, the priority is to assess the neurological status to determine the extent of central nervous system involvement. This will guide further treatment and interventions.

Choice C reason:

Assessing the cranial nerves is crucial in a client with suspected meningococcal meningitis. This assessment helps determine the extent of neurological impairment and can provide critical information about the progression of the disease. Early identification of neurological deficits can guide immediate and appropriate interventions to prevent further complications.

Choice D reason:

Decreasing environmental stimuli can help reduce discomfort for the client, especially if they are experiencing photophobia or other sensory sensitivities. However, this action does not address the immediate need to assess the client’s neurological status. It is a supportive measure that can be implemented after more critical assessments are completed.

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Correct Answer is ["B","C","E"]

Explanation

Choice A reason:

Assigning the client to a private room is not the priority action in this scenario. The focus should be on decontamination and preventing the spread of the unknown substance to others in the emergency department. Isolation measures can be considered after initial decontamination.

Choice B reason:

Removing the client and transport crew from the Emergency department is a priority action to prevent contamination of the area and exposure to other patients and staff. This step helps contain the potential hazard and ensures the safety of everyone in the department.

Choice C reason:

Contacting the decontamination team is essential for managing the situation. The decontamination team has the expertise and equipment to safely remove the unknown substance from the client and transport crew, reducing the risk of further exposure and contamination.

Choice D reason:

Calling the scene to identify the chemical can be helpful, but it is not the immediate priority. The focus should be on decontamination and ensuring the safety of the client and others. Identifying the chemical can be done concurrently or after initial decontamination efforts.

Choice E reason:

Immediately removing the saturated clothing from the client is a critical step in the decontamination process. Removing contaminated clothing helps reduce the client’s exposure to the substance and prevents further absorption through the skin.

A. Restrict drinking fluids before and during meals. B. Plan medication doses to occur before meals. C. Increase the amount of fat and carbohydrates in meals. D. Eat three large meals per day.

Correct Answer is B

Explanation

Choice A reason:

Restricting drinking fluids before and during meals is not an appropriate suggestion for improving nutritional status. While it might help prevent early satiety in some cases, it does not address the underlying issues related to Myasthenia gravis, such as muscle weakness affecting chewing and swallowing.

Choice B reason:

Planning medication doses to occur before meals is a crucial strategy for clients with Myasthenia gravis. Medications such as anticholinesterase agents can help improve muscle strength, making it easier for the client to chew and swallow food. This approach can enhance the client’s ability to consume adequate nutrition during meals.

Choice C reason:

Increasing the amount of fat and carbohydrates in meals might help with caloric intake, but it does not address the specific challenges faced by clients with Myasthenia gravis. The focus should be on strategies that improve the client’s ability to eat effectively, rather than just altering the macronutrient composition of meals.

Choice D reason:

Eating three large meals per day can be challenging for clients with Myasthenia gravis due to muscle fatigue. Smaller, more frequent meals are often recommended to help manage energy levels and ensure adequate nutrition without overwhelming the client.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is conducting triage of clients transported from a mass casualty incident (MCI). A client arrives saturated with an unknown substance and medical transport reports feeling dizzy. The nurse should prioritize which actions? SELECT ALL THAT APPLY

Correct Answer is ["B","C","E"]

Explanation

A nurse is providing care to a client with Myasthenia gravis who has lost 6 kg of weight over the past 2 months. What should the nurse suggest to improve this client’s nutritional status?

Correct Answer is B

Explanation

A nurse enters the room of a client and discovers the client with new right-sided weakness and slurred speech. Which of the following actions should the nurse take?

A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client?

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A nurse is caring for a client scheduled for a functional assessment who asks, “What is the purpose of this assessment?” How should the nurse most appropriately respond to the client?

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A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client?

A nurse is working with a community at risk for flooding. The nurse is aware that identification of at-risk populations, education of the residents about evacuation routes, and emergency shelters is an example of what level of the National Response Framework?