A nurse is contributing to the plan of care for a client who has viral meningitis. Which of the following interventions should the nurse recommend?
Measure the client's intake and output every 8 hr.
Dim the lighting in the client's room.
Monitor the client's temperature every 6 hr.
Initiate contact precautions for the client.
The Correct Answer is B
Choice A Reason:
Measuring the client's intake and output every 8 hours is a general nursing intervention but might not be specifically pertinent to managing viral meningitis.
Choice B Reason:
Dim the lighting in the client's room is correct. Meningitis often causes sensitivity to light (photophobia) due to the inflammation of the meninges surrounding the brain and spinal cord. Dimming the lighting in the client's room helps reduce discomfort and sensitivity to light, which is a common symptom of meningitis.
Choice C Reason:
Monitoring the client's temperature every 6 hours is a routine nursing practice, but in viral meningitis, more frequent temperature monitoring might be necessary, especially if the client shows signs of fever or instability.
Choice D Reason:
Initiating contact precautions for viral meningitis is not typically necessary because it's usually transmitted through respiratory secretions. Standard precautions for infection control, including proper hand hygiene, are usually sufficient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Suction equipment is recommended. This is a crucial supply to have at hand. During or after a seizure, the client might have excessive secretions or vomit, which could potentially obstruct their airway. Suction equipment helps clear the airway and maintain breathing, making it an essential item to have bedside.
Choice B Reason:
Padded tongue blades is incorrect. The use of padded tongue blades during a seizure is not recommended. Placing anything inside the mouth during a seizure could cause injury or pose a risk of choking. Keeping the airway clear and ensuring the client's safety is more important than attempting to manipulate the tongue.
Choice C Reason:
Backboard is incorrect.Backboards are typically used for spinal immobilization in cases of suspected spinal injury, not specifically for seizure management. Unless there's a concurrent injury or trauma, a backboard wouldn't be routinely necessary for a client having a seizure.
Choice D Reason:
Wrist restraints is incorrect. Restraints are generally not used for managing seizures. Using restraints during a seizure could potentially cause harm, restrict movement, and increase the risk of injury to the client. Restraints are not considered appropriate or safe for managing seizures.
Correct Answer is D
Explanation
Choice A Reason:
Preparing the sterile dressing supplies 30 min before the dressing change is correct. While it's crucial to have all supplies ready before starting the procedure, preparing them 30 minutes in advance might not align with the principles of maintaining sterility. It's generally best to prepare sterile supplies just before the procedure to minimize the risk of contamination.
Choice B Reason:
Don sterile gloves before removing the dressing is incorrect. Sterile gloves should indeed be worn during the dressing change, but they should be put on after removing the old dressing. This ensures that the clean gloves don't touch potentially contaminated surfaces during the removal of the old dressing.
Choice C Reason:
Disinfect the wound bed with alcohol before applying tape is incorrect. Using alcohol to disinfect the wound bed is not recommended as it can cause tissue irritation and delay wound healing. Sterile saline or another wound cleansing solution prescribed for wound care would be more appropriate to clean the wound bed. Additionally, applying tape directly to the wound is generally avoided to prevent further damage to the fragile tissues of a pressure ulcer.
Choice D Reason:
Offering the client pain medication before the procedure is correct. Providing pain medication before the procedure ensures the client's comfort and helps manage any discomfort or pain associated with the dressing change, particularly when dealing with a stage III pressure ulcer, which can be quite sensitive.
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