A nurse is planning care for a 6-year-old child who has bacterial meningitis. Which of the following nursing interventions is unnecessary in the client's plan of care?
Measure head circumference every shift
Admit the client to a private room
Place the client in a semi-Fowler's position
Implement seizure precautions
The Correct Answer is A
A. While monitoring for increased intracranial pressure is important, measuring head circumference every shift may not be necessary unless there is a specific indication or change in the child's condition.
B. Admitting the child to a private room is necessary to reduce the risk of spreading the infection to others.
C. Placing the child in a semi-Fowler's position can help reduce intracranial pressure and promote comfort.
D. Implementing seizure precautions is important, as children with bacterial meningitis are at risk for seizures.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Nurses are mandated reporters of child abuse, and informing the parent about the legal obligation to report is appropriate and transparent.
B. Reporting to a supervisor does not relieve the nurse of the responsibility to directly report suspected child abuse to the appropriate authorities.
C. While the nurse should be empathetic, the legal obligation to report takes precedence over discussing details with the parent.
D. In situations of suspected child abuse, it is the responsibility of the nurse, not the provider, to make the initial report.
Correct Answer is C
Explanation
A. Gastritis is not an infectious condition and is unlikely to be the source of the child's rheumatic fever.
B. Chickenpox is caused by a different pathogen (varicella-zoster virus) and is not associated with the development of rheumatic fever.
C. Rheumatic fever often follows untreated or inadequately treated streptococcal infections, particularly streptococcal pharyngitis (sore throat). A sibling with a recent sore throat is a significant piece of information.
D. Fifth disease is caused by parvovirus B19 and is not known to be a precursor to rheumatic fever.
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