A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority?
Document intake and output.
Administer antibiotics when available
Reduce environmental stimuli
Maintain seizure precaution
The Correct Answer is B
A) Document intake and output:
Documenting intake and output is an important nursing task, but it is not the top priority in a suspected case of bacterial meningitis. Timely administration of antibiotics to treat the infection takes precedence over documentation of intake and output.
B) Administer antibiotics when available.
Explanation:
Bacterial meningitis is a serious and potentially life-threatening infection of the membranes covering the brain and spinal cord. Rapid administration of antibiotics is crucial to effectively treat the infection and prevent its spread. Delay in antibiotic administration can lead to worsening symptoms and complications. Therefore, getting the appropriate antibiotics to the child as soon as they are available is the nurse's priority.
C) Reduce environmental stimuli:
Reducing environmental stimuli can be helpful in managing symptoms and providing comfort to the child with meningitis, but it is not the priority action. The immediate concern in a suspected case of bacterial meningitis is to treat the infection.
D) Maintain seizure precaution:
While maintaining seizure precautions is important, especially if the child has a history of seizures, it is not the top priority in a suspected case of bacterial meningitis. Administering antibiotics to treat the infection and prevent its progression is the primary concern.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Smokey brown urine:
This finding is not typically associated with nephrotic syndrome. Smokey brown urine might indicate the presence of blood in the urine, which can be seen in conditions such as hematuria or certain kidney infections.
B) Polyuria:
Polyuria refers to excessive urination and is not a primary characteristic of nephrotic syndrome. However, children with nephrotic syndrome may have decreased urine output due to the loss of fluid and proteins through the damaged kidney filters.
C) Facial edema:
Facial edema (swelling of the face) is a hallmark of nephrotic syndrome. The loss of albumin in the urine results in a decrease in oncotic pressure (a force that helps keep fluid in the blood vessels), leading to fluid accumulation in the interstitial spaces, including the face, ankles, and abdomen.
D) Hypertension:
Hypertension (high blood pressure) is not a typical finding of nephrotic syndrome itself. However, it's possible for kidney damage to lead to secondary hypertension. In nephrotic syndrome, low levels of albumin can trigger the renin-angiotensin-aldosterone system, which can contribute to increased blood pressure.
Correct Answer is C
Explanation
A. Assume you made a mistake and report out the same head circumference as before.
Incorrect Explanation: Assuming a mistake without taking proper action might not be the best approach.
Explanation: While it's good to consider the possibility of human error, healthcare professionals should prioritize accurate measurements and follow appropriate protocols when discrepancies arise.
B. Take Vital Signs.
Incorrect Explanation: Taking vital signs might not directly address the concern about the head circumference measurement.
Explanation: Vital signs (like heart rate, respiratory rate, blood pressure) are important indicators of a patient's overall health, but they may not directly address the issue of the head circumference measurement discrepancy.
C. Report to the MD/NP/PA in charge of the patient the head circumference that you obtained as well as the patient's current status. Expect that they will also re-measure.
Correct Explanation: This is the best next step.
Explanation: When there's a discrepancy in a critical measurement like head circumference, it's important to communicate this to the responsible healthcare provider (MD/NP/PA). They need to be aware of any changes in the patient's condition and measurements, and they will likely want to re-measure or reassess the situation themselves to ensure accuracy.
D. Move your measuring tape to above the mid-forehead, so that your number matches the findings from the week before.
Incorrect Explanation: Fudging measurements to match previous data is not a professional or ethical approach.
Explanation: Altering measurements to match previous values, especially without proper indication, is not a responsible practice in healthcare. It's essential to ensure accurate and honest documentation.
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