A nurse is caring for a school-age child who has heart failure. Which of the following interventions should the nurse implement?

Rationale for correct choices:

• Seizures: Clients with meningitis are at risk for seizures due to meningeal irritation, high fever, and increased intracranial pressure. Neurological complications arise as the infection spreads within the central nervous system, disrupting electrical activity in the brain.

• Level of consciousness: The adolescent is lethargic, drowsy, and irritable when aroused, which reflects altered neurological status. This finding indicates cerebral involvement, which increases the likelihood of seizure activity as the illness progresses.

Rationale for incorrect choices:

• Lyme disease: This condition is caused by tick bites and typically presents with erythema migrans rash, arthralgia, and fatigue, not acute fever, photophobia, or purpuric rash as seen here.

• Pneumonia: Respiratory involvement would present with abnormal breath sounds, cough, or hypoxemia, but this client has clear lung sounds and normal oxygen saturation, making pneumonia unlikely.

• Mononucleosis: This condition usually causes fever, pharyngitis, and lymphadenopathy, but the client’s cervical nodes are normal and their presentation aligns more with meningitis.

• Constipation: Gastrointestinal complications such as constipation are not relevant here since bowel sounds are active, the abdomen is soft, and there are no reports of decreased stooling.

• Abdominal findings: The abdomen is soft, flat, and with normal bowel sounds, which provides no evidence of an abdominal complication linked to meningitis risk.

• Rash: While the purpuric rash supports the diagnosis of meningococcal meningitis, it is not the primary indicator of seizure risk. Neurological status is a stronger predictor of seizure development.

• Cervical lymph nodes: These are normal without edema or tenderness, ruling out lymphatic involvement as a significant concern in this scenario.

• Breath sounds: Breath sounds are clear and equal bilaterally, which excludes a respiratory complication such as pneumonia as the risk factor linked to seizures.

A. Increased appetite: Cefazolin, a cephalosporin antibiotic, does not typically cause an increase in appetite. Instead, gastrointestinal upset such as nausea, vomiting, or diarrhea is more common with this class of drugs.

B. Nausea: Gastrointestinal disturbances, including nausea, vomiting, and diarrhea, are frequent adverse effects of cefazolin. The nurse should monitor for these symptoms as they can affect fluid and nutritional status, especially in children.

C. Hypertension: Cefazolin is not associated with increased blood pressure. Adverse effects more commonly involve gastrointestinal symptoms, hypersensitivity reactions, and, in rare cases, nephrotoxicity or superinfections.

D. Constipation: Constipation is not a typical adverse effect of cefazolin therapy. Instead, diarrhea is more commonly reported due to alterations in normal gastrointestinal flora during antibiotic use.