A nurse is caring for a newly admitted client who has bacterial meningitis. Which of the following actions should the nurse take?

Monitor the client for hypoglycemia.

Perform range-of-motion exercises once per shift

Place the client in high-Fowler's position.

Implement seizure precautions.

Answer and Explanation

The Correct Answer is D

Rationale:

A. Monitor the client for hypoglycemia: Hypoglycemia is not a common complication of bacterial meningitis. More relevant concerns include increased intracranial pressure, fever, and potential neurological damage, rather than altered glucose metabolism.

B. Perform range-of-motion exercises once per shift: While maintaining mobility is important, this is not a priority during the acute phase of bacterial meningitis. The client may be photophobic, confused, or in too much discomfort for routine exercises early in treatment.

C. Place the client in high-Fowler's position: High-Fowler’s can increase discomfort and may worsen meningeal irritation. A more appropriate position is 30 degrees with head midline to promote venous drainage and reduce intracranial pressure.

D. Implement seizure precautions: Seizures are a potential complication of bacterial meningitis due to inflammation, increased intracranial pressure, and irritation of the cerebral cortex. Seizure precautions are a critical safety measure in the acute phase of care.

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Correct Answer is A

Explanation

Rationale:

A. Limited hip abduction: Limited abduction of the hips in a 1-month-old can indicate developmental dysplasia of the hip (DDH). This finding warrants further evaluation, such as ultrasound imaging, to rule out structural abnormalities and initiate early treatment if needed.

B. Equal leg length: Equal leg length is a normal finding and does not require intervention. Leg length discrepancies are more concerning and often associated with hip dislocation or other musculoskeletal conditions.

C. Symmetric gluteal and thigh skin folds: Symmetry in the gluteal and thigh folds is a reassuring sign that typically rules out DDH. Asymmetry would be more suggestive of a hip abnormality requiring follow-up.

D. Femoral head remains in the acetabulum during the Barlow maneuver: This is a normal finding. The Barlow test assesses for hip instability, and if the femoral head remains stable within the socket, no further evaluation is needed.

A. Fibrocystic breast condition B. Hypertension C. Fibromyalgia D. Asthma

Correct Answer is B

Explanation

Rationale:

A. Fibrocystic breast condition: This benign breast disorder does not interfere with the use of oral contraceptives. In fact, hormonal birth control may sometimes reduce breast pain and nodularity associated with this condition.

B. Hypertension: High blood pressure is a known contraindication for oral contraceptive use, especially if it is uncontrolled. Estrogen-containing contraceptives can further elevate blood pressure and increase the risk of cardiovascular events such as stroke or myocardial infarction.

C. Fibromyalgia: Fibromyalgia does not interact with oral contraceptives and is not a contraindication. While hormonal changes may influence pain perception, there is no direct risk in using contraceptives for someone with this condition.

D. Asthma: Asthma is not a contraindication to using oral contraceptives. There is no evidence that hormonal contraceptives worsen asthma symptoms or interfere with its management.

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A nurse is caring for a newly admitted client who has bacterial meningitis. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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