What intervention(s) would the nurse caring for a child with infectious meningitis include? (Select all that apply.)

Observation for increasing intracranial pressure

Isolation precautions

Turn lights on to brighten the room

Preparation for lumbar puncture

Apply seizure precautions

Answer and Explanation

Correct Answer : A,B,D,E

A. Observation for increasing intracranial pressure is a critical intervention in the care of a child with infectious meningitis. Meningitis can lead to inflammation of the meninges, which may result in increased pressure within the skull.

B. Isolation precautions may be necessary depending on the causative organism and mode of transmission of the infectious meningitis. Bacterial meningitis, for example, may require droplet precautions to prevent the spread of infection to others.

D. Lumbar puncture (also known as a spinal tap) is a diagnostic procedure often performed to collect cerebrospinal fluid (CSF) for analysis in cases of suspected meningitis. It is an essential intervention in the diagnostic workup of infectious meningitis as it helps identify the causative organism and guide appropriate treatment.

C. Seizure precautions are important for children with infectious meningitis, as meningitis can increase the risk of seizures due to inflammation and irritation of the brain.

C. Bright lights can exacerbate symptoms such as headache and photophobia (sensitivity to light) in patients with meningitis, especially during the acute phase of illness. Therefore, it is not advisable to turn lights on to brighten the room for a child with infectious meningitis.

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Correct Answer is C

Explanation

C. Clubbing, characterized by bulbous enlargement of the fingertips and nail bed, is a result of chronic hypoxia in tetralogy of Fallot. In tetralogy of Fallot, there is a right-to-left shunting of blood due to the presence of a ventricular septal defect, overriding aorta, pulmonary stenosis, and right ventricular hypertrophy. This leads to reduced oxygenation of blood and chronic hypoxia, which can result in clubbing of the fingertips over time.

A This option is not the primary explanation for clubbing in tetralogy of Fallot. While decreased cardiac output may contribute to some manifestations of the condition, clubbing specifically results from chronic hypoxia rather than decreased cardiac output alone.

B Clubbing is not directly caused by a left-to-right shunting of blood. Instead, it is associated with chronic hypoxia, which can occur due to right-to-left shunting of blood in tetralogy of Fallot.

D Congestive heart failure may occur in individuals with tetralogy of Fallot but it is not the primary cause of clubbing. Clubbing in tetralogy of Fallot is primarily attributed to chronic hypoxia rather than heart failure alone.

A. Blood glucose 140 mg/dL B. Serum sodium 156 mEq/L C. RBC 3.2 million/ul D. Oxygen saturation 85%

Correct Answer is D

Explanation

D. An oxygen saturation level of 85% is significantly below the normal range and indicates hypoxemia (low blood oxygen levels). This finding is concerning, especially in a child with cystic fibrosis, which can lead to respiratory complications such as airway obstruction, infection, or mucus plugging.

A. A blood glucose level of 140 mg/dL is within the normal range for children, so this finding would not typically require immediate reporting to the provider.

B. A serum sodium level of 156 mEq/L is significantly elevated and above the normal range. However, hypoxia is the priority.

C. A red blood cell (RBC) count of 3.2 million/µL falls within the normal range for children, so this finding would not typically require immediate reporting to the provider.

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What intervention(s) would the nurse caring for a child with infectious meningitis include? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The parent of a 1-year-old child with tetralogy of Fallot asks the nurse, "Why do my child's fingertips look like that?" On what understanding does the nurse base a response?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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