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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Related Questions
Correct Answer is A
Explanation
A. This is a common postictal manifestation after a generalized tonic-clonic seizure. Following the intense muscle activity and convulsions during the seizure, the child may experience exhaustion and feel sleepy. The postictal state often involves a period of drowsiness or even brief loss of consciousness.
B. Restlessness is less likely to be observed immediately after a generalized tonic-clonic seizure. Instead, the child is more likely to exhibit fatigue and lethargy as the body recovers from the seizure activity.
C. Anxiety may occur during or immediately after the seizure due to the sudden and frightening nature of the event. However, in the postictal period, anxiety typically diminishes as the child becomes more oriented and aware of their surroundings.
D. Nausea is not a typical postictal manifestation after a generalized tonic-clonic seizure. While some individuals may experience nausea or vomiting during the seizure (ictal phase), it is less common in the postictal period.
Correct Answer is B
Explanation
B Kawasaki disease primarily affects medium-sized arteries, including the coronary arteries. The inflammation associated with Kawasaki disease can weaken the walls of the blood vessels, leading to the formation of aneurysms, particularly in the coronary arteries. Coronary artery aneurysms are a hallmark complication of Kawasaki disease and can increase the risk of myocardial infarction and other cardiovascular problems.
A This option describes a possible consequence of Kawasaki disease. Kawasaki disease can cause inflammation of the blood vessels, including the coronary arteries, which can lead to the formation of coronary artery aneurysms. These aneurysms can disrupt blood flow to the heart muscle, leading to ischemia and potentially heart failure.
C Mitral valve stenosis is not a typical complication of Kawasaki disease. While Kawasaki disease can affect the cardiovascular system and lead to complications such as coronary artery aneurysms, it does not typically cause mitral valve stenosis.
D Atherosclerosis is not a direct consequence of Kawasaki disease. Kawasaki disease primarily involves inflammation of the blood vessels rather than changes in lipid levels, which are more commonly associated with conditions such as hyperlipidemia or familial hypercholesterolemia.
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