A nurse in the emergency department is caring for a child who has a temperature of 39.1° C (102.4° F) and a suspected diagnosis of bacterial meningitis. Which of the following actions should the nurse take first?
Administer an antipyretic to the child.
Dim the lights in the child's room.
Implement droplet precautions for the child.
Prepare the child for a lumbar puncture.
The Correct Answer is C
A. "Administer an antipyretic to the child." While managing fever with antipyretics is important, it is not the immediate priority. Ensuring the child's safety and preventing the spread of infection are more urgent.
B. "Dim the lights in the child's room." While dimming the lights can help reduce discomfort and sensitivity in a child with meningitis, it is not the first priority. Implementing precautions and addressing infection control is more critical initially.
C. "Implement droplet precautions for the child." Bacterial meningitis is a communicable disease that can be spread via respiratory droplets. Implementing droplet precautions is crucial to prevent the spread of the infection to others and protect healthcare workers. This action should be taken first to ensure proper infection control.
D. "Prepare the child for a lumbar puncture." A lumbar puncture is an important diagnostic procedure for confirming bacterial meningitis, but it should only be performed after appropriate precautions are in place. Ensuring infection control measures are followed first is essential before proceeding with any diagnostic or treatment procedures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Neck vein distention is incorrect. Neck vein distention is not a common symptom of aspirin poisoning. It might be seen in conditions like heart failure but is not typically associated with aspirin toxicity.
Choice B Reason:
Polyuria is incorrect. Excessive urination (polyuria) is not a typical symptom of acute aspirin poisoning. Aspirin toxicity more commonly presents with symptoms related to the central nervous system, respiratory distress, metabolic acidosis, and temperature dysregulation.
Choice C Reason:
Hyperpyrexia is correct. Acute aspirin poisoning can lead to an increased body temperature (hyperpyrexia) due to its effects on the central nervous system and interference with the body's temperature regulation mechanisms. Aspirin toxicity can result in alterations in the hypothalamus, leading to an elevated body temperature.
Choice D Reason:
Jaundice is incorrect. Jaundice, the yellowing of the skin and eyes, is not a characteristic finding of acute aspirin poisoning. It is more commonly associated with liver dysfunction or certain types of liver diseases but is not a typical manifestation of aspirin toxicity.
Correct Answer is C
Explanation
Choice A Reason:
A school-age child who has diabetes mellitus and a blood glucose of 200 mg/dL. A blood glucose level of 200 mg/dL in a child with diabetes may require management but is not an immediate life-threatening situation.
Choice B Reason:
A toddler who has nephrotic syndrome and facial edema. Facial edema in a child with nephrotic syndrome requires assessment and potential intervention but might not present an immediate threat to life compared to an airway obstruction.
Choice C Reason:
A preschool-age child who has a muffled voice and no spontaneous cough. The combination of muffled voice and the absence of spontaneous cough can be indicative of an upper airway obstruction, which can be life-threatening. This requires immediate assessment and intervention to ensure the child's airway is clear and that breathing is not compromised.
Choice D Reason:
An adolescent who has Crohn's disease and a recent weight loss of 5 kg (11 lb). Weight loss in an adolescent with Crohn's disease is concerning but might not represent an immediate life-threatening situation compared to a potential airway obstruction.
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