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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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Choice A reason:

Secondary prevention involves early detection and treatment of disease to halt its progression. Examples include screening tests and early interventions. Advising a client with osteoporosis to consume dairy products is not aimed at early detection but rather at preventing the onset of complications by ensuring adequate calcium intake.

Choice B reason:

Primary prevention aims to prevent the onset of disease or injury before it occurs. This includes measures such as vaccinations, lifestyle modifications, and dietary recommendations. Advising a client with osteoporosis to consume three servings of milk or dairy products daily is a primary prevention strategy. It helps to maintain bone density and prevent fractures by ensuring adequate calcium and vitamin D intake.

Choice C reason:

Proactive prevention is not a standard term used in public health or medical practice. The recognized levels of prevention are primary, secondary, and tertiary. Therefore, this option is not applicable in this context.

Choice D reason:

Tertiary prevention focuses on managing and mitigating the effects of an existing disease to prevent further complications and improve quality of life. This includes rehabilitation and ongoing treatment for chronic conditions. While advising a client with osteoporosis to consume dairy products can be part of managing the condition, it is primarily a preventive measure to avoid further bone loss and fractures, aligning more with primary prevention.

A. A negative-pressure isolation room B. A private room C. A semi-private room with a client who has pediculosis capitis D. A positive-pressure isolation room

Correct Answer is B

Explanation

Choice A: A negative-pressure isolation room

A negative-pressure isolation room is typically used for patients with airborne infections, such as tuberculosis or measles, to prevent the spread of infectious agents through the air. Scabies, however, is primarily transmitted through direct skin-to-skin contact and occasionally through contact with contaminated clothing or bedding. Therefore, a negative-pressure isolation room is not necessary for a scabies patient1.

Choice B: A private room

A private room is the most appropriate choice for a client with scabies. This type of room helps prevent the spread of the infestation to other patients and allows for better control of the environment. Scabies is highly contagious and can spread through direct contact with the infested person or indirectly through contaminated items. Isolating the patient in a private room minimizes the risk of transmission and allows for proper infection control measures to be implemented2.

Choice C: A semi-private room with a client who has pediculosis capitis

Placing a scabies patient in a semi-private room with another patient, even one with a different parasitic infection like pediculosis capitis (head lice), is not advisable. Both conditions are highly contagious, and cohabitation increases the risk of cross-contamination and further spread of both infestations. Each condition requires specific treatment and isolation protocols to effectively manage and prevent outbreaks3.

Choice D: A positive-pressure isolation room

A positive-pressure isolation room is designed to protect immunocompromised patients from external contaminants by ensuring that air flows out of the room rather than in. This type of room is not suitable for a scabies patient, as it does not address the primary mode of transmission for scabies, which is direct contact. The focus for scabies management should be on preventing direct and indirect contact with others4.

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Naxlex Comprehensive Predictor Exams

A nurse advises a client with osteoporosis to have three servings of milk or dairy products daily. Which of the following levels of prevention is being used by the nurse?

Correct Answer is B

Explanation

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?

Correct Answer is B

Explanation

An occupational health nurse in the clinic of an industrial plant is developing a guidebook for clinic workers. Which of the following actions should the nurse include as a secondary prevention strategy?

A nurse is educating nursing students on the importance of client-centered community-based care. The nurse understands that which of the following principles is most essential to client-centered, community-based care in nursing?

The school nurse identifies 12 students with confirmed cases of influenza A. The families of the children are advised to keep the children home for a minimum of 5 to 7 days. Which of the following is an appropriate action by the nurse?

The community health nurse is educating new nurses on the spread of infectious diseases. The nurse utilizes which of the following approaches to explain the factors that allow the reproduction and spread of infectious disease?

A community health nurse is conducting an educational program on various environmental pollutants. The nurse should emphasize that clients who have which of the following disorders are especially vulnerable to ozone effects?

The nurse is creating an education plan for a client who has a recent diagnosis of Multiple Sclerosis (MS). Which of the following interventions should the nurse include in the client’s plan?

A nurse is providing education regarding biologic threats. When discussing anthrax, which of the following should be included as potential portals of entry? SELECT ALL THAT APPLY

A nurse is caring for a client who questions the need for cardiac rehabilitation, stating, “My heart is permanently damaged from the heart attack, so what’s the point of cardiac rehabilitation?” Which response should the nurse prioritize?