A nurse is contributing to the plan of care for a newly admitted adolescent.
A nurse is contributing to the plan of care for a newly admitted adolescent. Which of the following interventions should the nurse include?
Suction the client's airway every 2 hr.
Maintain the client's head of the bed at 30°.
Keep the client's room well lit.
Check the client's temperature every 8 hr.
The Correct Answer is B
A: Suctioning the client's airway every 2 hours is not indicated based on the provided information. The adolescent does not have a condition that compromises airway clearance, and routine suctioning can cause trauma or stimulate a vagal response, potentially leading to bradycardia.
B: Maintaining the client's head of the bed at 30° is appropriate for reducing intracranial pressure and facilitating venous drainage. The patient's symptoms of nuchal rigidity and severe headache suggest increased intracranial pressure, possibly due to meningitis, which is supported by the diagnostic results.
C: Keeping the client's room well lit is not advisable as the patient reports photophobia, which is a sensitivity to light. A well-lit room could exacerbate discomfort and pain.
D: Checking the client's temperature every 8 hours is important but not the priority intervention. The patient's condition requires more frequent monitoring due to the positive blood culture and sensitivity, indicating an active infection. More frequent temperature checks would be warranted.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Children with attention deficit hyperactivity disorder (ADHD) benefit from frequent breaks in activities. Short, focused periods of activity followed by breaks can help them maintain attention and focus.
Choice B reason:
While providing long-term goals is important for building self-esteem, it may not directly address the child's learning style associated with ADHD.
Choice C reason:
Administering medication at bedtime may not be the most effective timing for managing ADHD symptoms. The timing and dosing of ADHD medications should be discussed with the child's healthcare provider.
Choice D reason:
Children with ADHD benefit from consistent routines rather than constantly changing ones. A predictable routine can help them feel more organized and focused.
Correct Answer is C
Explanation
Choice A reason:
A maculopapular rash may be an allergic reaction to the antibiotic. While this should be reported, wheezing is a more urgent concern.
Choice B reason:
A headache may be a side effect of the antibiotic, but it is not as urgent as wheezing.
Choice C reason:
Wheezing can indicate a potential serious allergic reaction or anaphylaxis to the antibiotic. This is the priority finding to report to the provider.
Choice D reason:
An increased pulse may be a side effect of the antibiotic, but it is not as urgent as wheezing.
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