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 C
Explanation
Choice A Reason:
“I'm going to take your heart rate”. This statement is incorrect. Monitoring vital signs like heart rate is essential in assessing a client's condition. However, in this scenario, the client's report of hives, itching, and a potential allergic reaction is more indicative of an immediate concern for anaphylaxis. While monitoring heart rate is relevant, assessing for signs of anaphylaxis, especially difficulty breathing, takes precedence due to the urgency of potential respiratory distress.
Choice B Reason:
"I need to give you diphenhydramine". This statement is incorrect, administering an antihistamine like diphenhydramine can help alleviate allergic symptoms, including itching and hives. However, confirming the severity of the reaction and ensuring there are no life-threatening symptoms such as breathing difficulties is the immediate priority before administering any medication.
Choice C Reason:
"Are you having difficulty breathing?" This statement is correct. This question directly assesses the client's respiratory status, a crucial indicator of anaphylaxis. If the client is experiencing difficulty breathing, it indicates a severe allergic reaction that requires immediate intervention and emergency medical attention. Recognizing and addressing potential respiratory distress is of utmost importance in managing an allergic reaction to medication.
Choice D Reason:
"Do you have any allergies to medications? This statement is incorrect. Understanding the client's medical history, including allergies, is crucial. However, in this acute situation where the client is already experiencing symptoms of a potential allergic reaction shortly after receiving penicillin, addressing the current symptoms and assessing for signs of anaphylaxis is the most immediate concern.
Correct Answer is D
Explanation
Choice A Reason:
Polyuria is incorrect. Peritonitis doesn’t directly influence urine output. Polyuria (increased urine production) is more commonly associated with conditions affecting the kidneys or diabetes mellitus rather than peritonitis.
Choice B Reason:
Peripheral edema is incorrect. Peritonitis typically involves abdominal symptoms and signs rather than peripheral issues like edema. Edema can be related to heart, kidney, or circulatory system problems, but it's not a typical manifestation of peritonitis.
Choice C Reason:
Decreased respirations is incorrect. Peritonitis can cause pain and discomfort, which might affect the depth of breathing or result in shallow breathing due to guarding against abdominal pain. However, decreased respirations as a specific finding wouldn't commonly be expected in peritonitis. Pain might cause shallow breathing, but it wouldn't lead to a consistent decrease in respiratory rate.
Choice D Reason:
Absent bowel sounds is correct. Peritonitis is an inflammation of the peritoneum, the lining of the abdominal cavity. This condition often leads to the loss or significant reduction of bowel sounds due to the irritation and inflammation of the abdominal structures.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today