The nurse is caring for a client with a headache, nuchal rigidity, petechial rash, and fever. What interventions are the priority for the nurse to implement? Select all that apply.
Keep the client in a low stimulus environment
Assist with lumbar puncture
Administer the meningococcal vaccine for treatment.
Initiate intravenous antibiotics
Assess neurologic status daily
Implement seizure precautions
Implement droplet precautions
Correct Answer : A,B,D,F,G
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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Related Questions
Correct Answer is D
Explanation
A. Zinc ointment is appropriate to protect skin from breakdown due to diarrhea, but it does not address the client’s most urgent physiologic need.
B. Probiotics may support gut health, but oral administration is not appropriate when the client cannot hold down fluids and is at risk for dehydration.
C. Obtaining a stool specimen is important for identifying the infectious cause, but it is not the immediate priority.
D. The client has had several days of diarrhea and is unable to tolerate oral fluids, placing them at high risk for severe dehydration and electrolyte imbalance. Administering IV fluids at 125 mL/hr is the priority intervention to restore fluid balance and prevent hypovolemic shock.
Correct Answer is B
Explanation
A. Regular shampoo does not kill or remove lice or nits. Prescription or over-the-counter pediculicide is required.
B. Nits should be removed using an extra-fine-tooth comb or tweezers after treatment to prevent reinfestation.
C. It is difficult for parents to distinguish viable from nonviable nits, so all visible nits should be removed.
D. Cutting the child’s hair is unnecessary and not recommended for management.
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