The nurse is caring for a patient with bacterial meningitis caused by Haemophilus influenzae type B. What should the nurse include in the patient's plan of care?
Monitoring of neurologic status
Infusion of large volumes of isotonic intravenous fluids
Standard precautions
Distraction activities to reduce long periods of sleep.
The Correct Answer is A
Choice A reason: This is correct. Monitoring of neurologic status is a priority intervention for a patient with bacterial meningitis, as the infection can cause inflammation and damage to the brain and spinal cord. The nurse should assess the patient's level of consciousness, pupillary response, cranial nerve function, and signs of increased intracranial pressure.
Choice B reason: This is incorrect. Infusion of large volumes of isotonic intravenous fluids is not indicated for a patient with bacterial meningitis, as it can worsen the cerebral edema and increase the intracranial pressure. The patient should receive adequate hydration, but not excessive fluids.
Choice C reason: This is incorrect. Standard precautions are not sufficient for a patient with bacterial meningitis, as the infection can be transmitted through respiratory droplets. The patient should be placed on droplet precautions, which include wearing a mask, gloves, and gown, and limiting the contact with other patients and visitors.
Choice D reason: This is incorrect. Distraction activities to reduce long periods of sleep are not appropriate for a patient with bacterial meningitis, as the patient may need rest and sedation to reduce the agitation and pain. The nurse should provide a quiet and dark environment, and avoid unnecessary stimuli that can increase the intracranial pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Eyes are deviated to the right is an assessment finding that indicates increased intracranial pressure and possible herniation of the brain. It is a sign of cranial nerve III palsy, which affects the movement of the eye and the size of the pupil. It is a medical emergency that requires immediate intervention.
Choice B reason: Amnesia to the cause of the trauma is an assessment finding that indicates memory loss and possible concussion. It is a sign of damage to the temporal lobe, which is involved in memory formation and retrieval. It is not a medical emergency, but it requires further evaluation and monitoring.
Choice C reason: Complaint of mild headache is an assessment finding that indicates pain and discomfort. It is a common symptom of traumatic brain injury, but it is not specific or severe. It can be managed with analgesics and rest.
Choice D reason: Pupils constrict from 5 mm to 2 mm with direct light stimulus is an assessment finding that indicates normal pupillary response. It is a sign of intact cranial nerve II and III function, which control the vision and the pupil size. It is not a cause for concern or notification.
Correct Answer is B
Explanation
Choice A reason: "You need to bring your child to the emergency department immediately and have the stool tested for blood." is not an appropriate response by the nurse. Black stools can be a sign of gastrointestinal bleeding, which is a serious condition that requires immediate medical attention. However, in this case, the black stools are most likely caused by the iron supplement, which can change the color and consistency of the stool. Therefore, there is no need to panic or rush to the emergency department.
Choice B reason: "Greenish black stools are normal when oral iron supplements are being administered." is the most appropriate response by the nurse. It is a factual and reassuring statement that explains the reason for the stool color change and educates the mother about the expected side effect of the iron supplement. It also encourages the mother to continue the treatment for the child's anemia.
Choice C reason: "You should stop administering the daily iron supplement." is not an appropriate response by the nurse. It is a harmful and incorrect advice that contradicts the prescribed treatment for the child's anemia. Stopping the iron supplement can worsen the child's condition and lead to complications such as growth retardation, cognitive impairment, or heart failure.
Choice D reason: "Don't worry about it." is not an appropriate response by the nurse. It is a dismissive and vague statement that does not address the mother's concern or provide any information or education. It can also undermine the mother's trust and confidence in the nurse and the health care system.
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