A nurse is assisting with the care of a client who has suspected meningitis and a decrease level of consciousness. Which of the following actions should the nurse take?
Prepare the client for liver biopsy
Put the client in a protective environment
Position the client dorsal recumbent
Place the client on NPO status
The Correct Answer is D
D. The correct action would be to place the client on NPO (Nothing by Mouth) status, option D. This is because a decreased level of consciousness can increase the risk of aspiration.
A. Liver biopsy is not indicated for suspected meningitis with a decreased level of consciousness. Liver biopsy is a procedure used to obtain a sample of liver tissue for diagnostic purposes, typically to evaluate liver function or diagnose liver diseases.
B. A protective environment (option B) is more related to immunocompromised patients. In the case of decreased level of consciousness, preventing aspiration is key.
C. Dorsal recumbent position refers to lying on the back with the knees flexed. While this position may be suitable for certain medical procedures or examinations, it is not specifically indicated for a client with suspected meningitis and a decreased level of consciousness.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The absence of the dorsalis pedis pulse in the right foot is concerning and could indicate compromised circulation to the extremity. It is essential to notify the healthcare provider promptly so that further assessment and intervention can be initiated to address the circulation issue and prevent potential complications such as ischemia or tissue damage.
B. Administering an analgesic may be necessary to manage the child's pain, especially if they are experiencing discomfort due to the femur fracture. However, addressing the absent dorsalis pedis pulse takes priority as it suggests a potential vascular problem that requires immediate attention.
C. Releasing the skin traction may not be appropriate at this point without further assessment and guidance from the healthcare provider. Skin traction is often used to temporarily stabilize fractures and reduce pain, and releasing it without proper evaluation could potentially exacerbate the injury or compromise the child's comfort and stability.
D. Applying ice to the extremity is not indicated in this situation. Ice application is typically used for acute injuries to reduce swelling and inflammation, but it is not appropriate when there is concern about compromised circulation.
Correct Answer is A
Explanation
A. Prompt initiation of appropriate antibiotics is essential to prevent the spread of infection, alleviate symptoms, and promote healing.
B. Surgical debridement of necrotic tissue is often necessary for treating acute osteomyelitis, especially if there is extensive tissue damage or the formation of abscesses. Surgical intervention aims to remove infected and dead tissue, reduce bacterial load, and promote wound healing.
C. Antipyretic therapy, such as acetaminophen or ibuprofen, may be administered to reduce fever and alleviate associated symptoms in clients with acute osteomyelitis. While fever management is important for comfort and overall well-being, it may not be the immediate priority unless the fever is high or causing significant distress.
D. Adequate nutrition and hydration support immune function, tissue repair, and overall recovery. However, while important for long-term management, optimizing nutrition and hydration may not be the immediate priority unless the client is severely malnourished or dehydrated.
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