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:
"We will apply lotion to the skin under the straps." Applying lotion under the straps might create moisture, interfere with the harness's function, or cause skin irritation. It's generally recommended to avoid lotions or creams under the straps.
Choice B Reason:
"We should expect our baby to wear this harness for 2 weeks." The duration for wearing a Pavlik harness can vary significantly depending on the severity of the hip dysplasia and the infant's response to treatment. The duration is determined by the healthcare provider's assessment and may extend beyond 2 weeks.
Choice C Reason:
"We will place the diaper under the straps." Placing the diaper under the straps helps prevent skin irritation and chafing caused by the straps rubbing against the skin. It ensures that the skin remains protected and reduces the risk of skin breakdown or discomfort for the infant.Pavlik harnesses are typically designed to keep the hips in a specific position, and diapers should be placed underneath to avoid leaks soiling the harness
Choice D Reason:
"We should adjust the straps daily." Adjusting the straps of a Pavlik harness should only be done by a healthcare professional to ensure proper positioning and safety.
Correct Answer is A
Explanation
Choice A Reason:
Shrug their shoulders against mild pressure. The accessory nerve controls the movement of the trapezius and sternocleidomastoid muscles. To assess this nerve, the nurse should ask the child to shrug their shoulders against mild resistance or pressure applied by the nurse's hands on the child's shoulders. This action assesses the strength and symmetry of the trapezius muscles.
Choice B Reason:
Move their tongue in all directions. This action assesses the function of the hypoglossal nerve (cranial nerve XII), which controls tongue movement.
Choice C Reason:
Follow a light in the six cardinal positions. This action assesses the function of the extraocular muscles and cranial nerves III, IV, and VI, which control eye movements.
Choice D Reason:
Show their teeth while smiling. This action primarily assesses the facial nerve (cranial nerve VII), which controls facial expressions, including smiling and showing teeth.
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