The emergency room nurse is admitting a client who is very drowsy. The client reports a sudden onset of fever, headache, vomiting and neck pain. The nurse notes a Glascow Coma Scale of 11. What is the priority nursing action

Assess the Glasgow Coma Scale and pupils

Initiate droplet precautions

Prepare for lumbar puncture

Encourage the adolescent to drink fluids

Answer and Explanation

The Correct Answer is B

A. Frequent neurological checks are important, but the priority action in this case is to prevent transmission of suspected meningitis, which is highly contagious.
B. The client’s symptoms (sudden fever, headache, vomiting, nuchal rigidity, altered level of consciousness) strongly suggest bacterial meningitis. The priority is to initiate droplet precautions immediately to protect staff and others from infection.
C. Preparing for a lumbar puncture is part of diagnostic confirmation, but infection control must be established first to prevent spread.
D. Oral fluids are not appropriate in a drowsy client with altered consciousness due to the risk of aspiration.

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Correct Answer is B

Explanation

A. A urine output of 750 mL/24 hr is low (oliguria) but not immediately life-threatening compared to electrolyte imbalances.

B. A potassium level of 5.2 mEq/L is slightly above normal and indicates hyperkalemia risk, which can progress rapidly to life-threatening cardiac dysrhythmias. This client is the highest priority for immediate assessment and intervention.

C. Depression is important but not the immediate priority in an acute setting compared to unstable lab values.

D. A scheduled dialysis client may be stable until treatment; the elevated potassium requires faster intervention.

A. Keep the client in a low stimulus environment B. Assist with lumbar puncture C. Administer the meningococcal vaccine for treatment. D. Initiate intravenous antibiotics E. Assess neurologic status daily F. Implement seizure precautions G. Implement droplet precautions

Correct Answer is ["A","B","D","F","G"]

Explanation

A. A low-stimulation environment helps reduce discomfort and agitation, which is important for clients with meningitis.

B. Assisting with a lumbar puncture is essential for confirming the diagnosis and guiding treatment.

C. The meningococcal vaccine is preventive, not a treatment for active infection. Antibiotics are the primary treatment.

D. Intravenous antibiotics should be initiated immediately to treat bacterial meningitis and reduce morbidity and mortality.

E. While assessing neurologic status is important, daily assessment alone is insufficient; continuous monitoring and early interventions are priority.

F. Seizure precautions are important because meningitis can increase the risk of seizures due to irritation of the meninges.

G. Droplet precautions are necessary to prevent transmission of Neisseria meningitidis, which is highly contagious.

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Blood Pressure	118/78 mmHg
Heart Rate	112 beats/minute
Respiratory Rate	22 breaths/minute
Temperature	102.8 F (39.3 C)
WBC	16000 (Ret: 4000-11000)
BUN	24 mg/dL (Ref: 8-20 mg/dL)
Creatinine	1.1 mg/dL (Ref: 0.6-1.2 mg/dL)

The emergency room nurse is admitting a client who is very drowsy. The client reports a sudden onset of fever, headache, vomiting and neck pain. The nurse notes a Glascow Coma Scale of 11. What is the priority nursing action

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