Which interventions would the nurse include in the plan of care for a patient with a diagnosis of bacterial meningitis?

Maintain the patient in a flat, supine position

Restrain the patient in bed.

Reduce the patient's environmental stimuli as much as possible

Increase the patient's fluid intake

Answer and Explanation

The Correct Answer is C

A.   A flat supine position is not recommended for patients with meningitis; they should be kept at a 30- degree angle to reduce ICP.

B.   Restraining the patient is unnecessary unless there is an immediate risk of harm, and it can cause distress.
C.   Reducing environmental stimuli helps minimize discomfort and risk of seizures, especially in meningitis, which causes hypersensitivity to light and sound.
D.   Fluid intake should be monitored carefully. Excessive fluids may increase ICP in a patient with meningitis.

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Correct Answer is A

Explanation

A. The priority in managing delirium is ensuring the patient's safety, as delirium increases the risk of falls, self-harm, and other dangerous behaviors. Close monitoring and protective measures are essential.
B. Oxygenation is important but not the first priority unless the patient shows signs of hypoxia or respiratory distress.
C. Pain management should be considered, but it is secondary to addressing the safety risks associated with delirium.
D. Infection should be investigated, but the immediate concern in delirium is safety due to the altered mental state.

Correct Answer is []

Explanation

Increased Intracranial Pressure (ICP)

Based on the patient’s clinical presentation, which includes a fall, slurred speech, weak cough reflex, restlessness, and a slight headache, the patient is at risk for increased intracranial pressure (ICP). The history of falling from a ladder could suggest a possible head injury, and the changes in speech and restlessness could be early signs of increasing ICP. The presence of a laceration on the left temple may also indicate a traumatic brain injury, which is a key risk factor for increased ICP.

Actions to Take:

Apply oxygen via cannula at 2 L/min

Oxygen is critical for brain tissue oxygenation, especially in patients with possible head injuries and ICP. The patient's oxygen saturation is 90% on room air, which is slightly low and requires supplementation to maintain adequate oxygen levels and reduce the risk of hypoxia, which can exacerbate increased ICP.

Elevate the head of the bed to 45 degrees

Elevating the head of the bed to 30-45 degrees can help improve venous drainage from the brain, thus reducing the risk of increased ICP. Positioning the patient in this way also helps reduce pressure on the brain and enhances cerebral perfusion.

Parameters to Monitor:

Level of consciousness (LOC)

Changes in the patient's level of consciousness are a key indicator of worsening ICP. The nurse should assess the patient’s alertness, orientation, and any deterioration in cognitive function or responsiveness. The patient's current orientation level is X2, meaning they are only oriented to person and place, which may signal a developing problem.

Vital signs

Monitoring vital signs, especially blood pressure, heart rate, and respiratory rate, is crucial in assessing the patient's neurological status. Changes in blood pressure (especially widening pulse pressure) or abnormal respiratory patterns can be early indicators of increased ICP. In particular, the patient's blood pressure (152/59) suggests a possible increased risk of ICP, with the systolic value elevated but the diastolic pressure relatively low. This could be a compensatory response to ICP or another issue.

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Which interventions would the nurse include in the plan of care for a patient with a diagnosis of bacterial meningitis?

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Naxlex Comprehensive Predictor Exams

Which are would be a priority of care for a patient who is being admitted to the hospital and its demonstrating signs of delirium?

Correct Answer is A

Explanation

Correct Answer is []

Explanation

Increased Intracranial Pressure (ICP)

Actions to Take:

Parameters to Monitor:

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