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A nurse is caring for a school-age child.

Complete the following sentence by using the lists of options.

The nurse should first

because of
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Rationale for correct choices:

  • Decrease environmental stimuli: The child presents with classic signs of meningitis (nuchal rigidity, positive Kernig sign, photophobia, headache, vomiting, irritability, and abnormal CSF findings). The priority nursing action is to reduce stimulation (light, noise, and activity) because meningitis causes increased intracranial pressure and severe neurologic irritability. Decreasing stimuli helps reduce discomfort and prevents worsening neurologic stress.
  • Light intolerance: Photophobia (light sensitivity) is a hallmark symptom of meningitis and directly explains the need to reduce environmental stimuli.

Rationale for incorrect choices:

  • Administer acetaminophen: While the child has a mild fever (100.9°F), this is not the priority over neurologic protection. Fever management is secondary to reducing CNS stimulation in suspected meningitis.
  • Implement droplet precautions: Although bacterial meningitis does require droplet precautions, the priority here is symptom management related to increased intracranial irritation (photophobia and CNS inflammation). The question asks for the first nursing action, which focuses on immediate comfort and neurologic protection rather than infection control initiation.
  • Temperature: Fever is present but is not the primary driver of the child’s acute neurologic symptoms or priority intervention compared to photophobia and CNS irritation.
  • Cerebrospinal fluid analysis results: These confirm meningitis but do not guide immediate nursing action; they are diagnostic data rather than a direct cause requiring intervention.


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Related Questions

Correct Answer is C

Explanation

Rationale:
A. Analgesics for clients on mechanical ventilation should not be given on a fixed schedule without assessment. Pain and sedation needs should be individualized and based on continuous assessment (e.g., pain scales, sedation scales such as RASS). Routine scheduled dosing every 8 hours may lead to over-sedation or under-treatment.

B. Suctioning should be performed as needed, not on a routine schedule. Indications include visible or audible secretions, decreased oxygen saturation, increased peak airway pressures, or signs of respiratory distress. Routine suctioning every 4 hours can cause mucosal trauma, hypoxia, and infection.

C. Elevating the head of the bed (typically 30–45 degrees or higher if tolerated) improves lung expansion, enhances oxygenation, reduces the risk of aspiration, and decreases the risk of ventilator-associated pneumonia (VAP). This is a standard evidence-based intervention for clients receiving mechanical ventilation.

D. While daily weight monitoring is often important in critically ill clients to assess fluid balance, especially in those receiving mechanical ventilation, weekly weights are too infrequent. Fluid shifts in critically ill patients can occur rapidly, so more frequent monitoring is typically required.

Correct Answer is A

Explanation

Rationale:
A. When a client is experiencing auditory hallucinations, the nurse should assess the content of the hallucinations to determine if they include harmful or command themes (e.g., self-harm or harm to others). Asking directly about what the client is hearing helps the nurse evaluate risk, maintain therapeutic communication, and better understand the client’s experience without reinforcing the hallucination as real.

B. Avoiding eye contact can be interpreted as disinterest or rejection and may increase the client’s anxiety or mistrust. With schizophrenia, maintaining appropriate eye contact (not excessive or intimidating) supports therapeutic rapport and communication.

C. This may be helpful in some cases to reduce environmental stimulation, but it is not the priority intervention. Isolation alone does not address the hallucination content or assess for potential risk. The nurse must first assess what the client is experiencing before implementing environmental interventions.

D. This is incorrect and unsafe. The nurse should never validate hallucinations as real because this reinforces the false perception. Instead, the nurse should acknowledge the client’s experience while gently presenting reality (e.g., “I understand you are hearing voices, but I do not hear them”).

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