What is the first action a nurse should take when bacterial meningitis is suspected in a client?
Initiate isolation precautions
Administer antibiotics after collecting cultures
Prepare for a lumbar puncture after ruling out increased ICP
Start IV fluid
The Correct Answer is A
A. Initiate isolation precautions — This is the first action the nurse should take. Bacterial meningitis is highly contagious (often spread via droplet transmission), and immediate isolation (droplet precautions) helps prevent spread to others.
B. Administer antibiotics after collecting cultures — This is a critical next step, but only after the client is placed in isolation to protect others.
C. Prepare for a lumbar puncture after ruling out increased ICP — While a lumbar puncture is important for diagnosis, increased ICP must be ruled out first, and this is not the immediate first action.
D. Start IV fluids — Supportive care is important, but it is not the priority over infection control measures.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Ischemia and neuronal death – Cerebral perfusion pressure (CPP) is the pressure needed to ensure adequate blood flow to the brain. If CPP drops too low, the brain doesn't receive enough oxygen and glucose, leading to ischemia and eventually neuronal death.
B. Improved cognitive function – Low CPP results in decreased oxygen and nutrient delivery, which impairs cognitive and neurological function.
C. Increased blood flow to the brain – Low CPP means reduced blood flow, not increased.
D. Undetectable intracranial glucose levels – While glucose delivery may decrease, levels are not necessarily undetectable and this is not the primary concern with low CPP.
Correct Answer is A
Explanation
A. Decerebrate posturing is characterized by extension and rigidity of the arms and legs, typically indicating damage to the midbrain or pons. It reflects severe brain injury.
B. Tonic-clonic seizures involve rhythmic muscle contractions but are not posturing.
C. Involuntary twisting and repetitive movements describe dystonia or chorea, not decerebrate posturing.
D. Uncontrolled jerking movements describe myoclonus or seizures, not decerebrate posturing.
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