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. Ice pops are often recommended after tonsillectomy to help soothe the throat and provide hydration.
B.Although ice cream is cold and can soothe the throat, it is not the best option immediately after surgery. Dairy products, including ice cream, can sometimes lead to increased mucus production, which could irritate the throat and make swallowing more difficult during the healing process.
C. Offering hot tea is not recommended immediately following a tonsillectomy. Hot beverages, including tea, can increase the risk of bleeding and discomfort at the surgical site.
D. Cranberry juice is not an appropriate choice immediately post-tonsillectomy. While hydration is essential for recovery, acidic or tart beverages like cranberry juice may irritate the surgical site and increase discomfort.
Correct Answer is B
Explanation
B. Leaning forward with the chin thrust out, often described as the "sniffing position," is a classic sign of airway obstruction, particularly in cases of epiglottitis. This positioning helps to maximize airway patency by opening the airway and reducing the risk of further obstruction.
A. Leaning forward with the chin thrust out is not typically associated with extreme fatigue. Instead, it is a specific positioning often seen in individuals with epiglottitis to help alleviate airway obstruction and facilitate breathing.
C. Leaning forward with the chin thrust out is not indicative of dehydration. Dehydration may present with other signs and symptoms such as dry mucous membranes, decreased urine output, sunken fontanelle (in infants), and poor skin turgor.
D. Pain may be present in a child with epiglottitis but leaning forward with the chin thrust out is not primarily indicative of pain. This positioning is primarily a compensatory mechanism to alleviate airway obstruction rather than a response to pain.
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