A nurse is planning care for a client who is experiencing seizures secondary to meningitis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

Place a tongue blade at the bedside.

Dim the overhead lights.

Assist the client to ambulate every 4 hr.

Apply a warming blanket.

Have suction equipment at the bedside.

Answer and Explanation

Correct Answer : B,E

A. Place a tongue blade at the bedside: Keeping a tongue blade at the bedside is not recommended because attempting to insert an object into the mouth during a seizure can cause injury to the teeth, gums, or airway. Instead, the focus should be on maintaining a safe environment and protecting the client from harm.

B. Dim the overhead lights: Meningitis can cause photophobia, or sensitivity to light, which can worsen discomfort and potentially trigger seizures. Dimming the lights helps reduce sensory stimulation and promotes comfort, decreasing the risk of further neurological agitation.

C. Assist the client to ambulate every 4 hr: Clients experiencing seizures should have activity restrictions to prevent falls and injuries. Ambulation should be supervised and only encouraged once the client is stable. Frequent rest is preferred to minimize exhaustion, which can contribute to seizure activity.

D. Apply a warming blanket: Meningitis can cause fever, but applying a warming blanket is not appropriate unless the client is experiencing hypothermia. Fever management typically involves antipyretics and cooling measures, such as tepid sponge baths or light clothing, rather than warming interventions.

E. Have suction equipment at the bedside: During a seizure, excessive secretions or impaired airway protection can lead to aspiration. Having suction equipment readily available allows for quick clearance of the airway once the seizure subsides, reducing the risk of respiratory complications.

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Correct Answer is B

Explanation

A. Wears an N95 mask when providing wound care: MRSA is transmitted via direct contact rather than airborne particles, so an N95 mask is unnecessary unless the client has a secondary airborne infection like tuberculosis. Standard contact precautions, including gloves and gowns, are sufficient to prevent transmission.

B. Wears clean gloves when caring for the client: MRSA requires contact precautions, which include wearing gloves when touching the client or contaminated surfaces. Gloves help prevent the spread of bacteria, particularly from wound drainage, body fluids, or contaminated equipment.

C. Remains 3 feet away from the client: MRSA does not require droplet precautions, which would necessitate maintaining a distance of 3 feet. Instead, direct skin-to-skin contact or contact with contaminated surfaces is the primary mode of transmission, requiring gloves and gowns rather than distance.

D. Disposes of isolation gown outside of the client's room: Isolation gowns should be removed inside the client’s room to prevent cross-contamination. Removing the gown before exiting the room reduces the risk of spreading MRSA to other areas and healthcare personnel.

A. Decorticate posturing B. Restlessness C. Papilledema D. Projectile vomiting

Correct Answer is B

Explanation

A. Decorticate posturing: This is a late sign of increased intracranial pressure, indicating severe brain dysfunction and potential herniation. Early signs of increased ICP typically involve subtle neurological changes such as restlessness, confusion, or irritability before progressing to abnormal posturing.

B. Restlessness: An early sign of increased ICP, restlessness occurs due to decreased cerebral perfusion and oxygenation, leading to subtle changes in mental status. Clients may also exhibit irritability, confusion, or difficulty following commands before more severe symptoms develop.

C. Papilledema: Swelling of the optic disc, or papilledema, is a later sign of increased ICP and occurs due to prolonged pressure on the optic nerve. It is typically detected on an ophthalmic exam rather than presenting as an early symptom.

D. Projectile vomiting: Vomiting without nausea is a later sign of increased ICP, often associated with brainstem involvement. Early manifestations tend to involve altered mental status before progressing to severe symptoms such as vomiting or posturing.

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A nurse is planning care for a client who is experiencing seizures secondary to meningitis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

Nursing Test Bank

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