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
Pulse rate 98/min: A pulse rate of 98 beats per minute is within the expected range for a 2-year-old child (normal range: 70-110 bpm). This finding is generally considered normal for this age and may not require immediate reporting.
Choice B Reason:
Temperature 37.2° C (99° F): A temperature of 37.2°C (99°F) is slightly elevated but is within the range of low-grade fever in children. However, at a well-child visit, this temperature might not be immediately alarming, especially if the child doesn't exhibit other signs of illness.
Choice C Reason:
Blood pressure 118/74 mm Hg:This reading is higher than the normal range for a 2-year-old child. High blood pressure in a young child should be evaluated further to determine the cause and need for intervention.
Choice D Reason:
Respiratory rate 26/min: The normal respiratory rate for a 2-year-old child typically ranges from 20 to 30 breaths per minute. A respiratory rate of 26 breaths per minute is within this range and may not warrant immediate concern.
Correct Answer is B
Explanation
Choice A Reason:
"Consume 1,500 to 1,700 calories per day." Caloric needs vary among individuals based on factors like age, sex, activity level, and growth rate. While this calorie range might be suitable for some adolescents, it's not universally applicable. Individual energy needs should be assessed based on various factors.
Choice B Reason:
“Increase the amount of your dietary iron intake." During adolescence, especially in menstruating females, the body's iron requirements increase due to the onset of menstruation and rapid growth. Encouraging adequate intake of dietary iron-rich foods is important to prevent iron deficiency anemia.
Choice C Reason:
"Decrease your vitamin D intake once you start to menstruate." Vitamin D is important for bone health, and menstruation doesn't warrant a decrease in vitamin D intake. Adequate vitamin D intake remains important for bone health, especially during adolescence when bone growth is significant.
Choice D Reason:
"Limit your sodium intake to 3,000 milligrams per day." While excessive sodium intake is a concern, the recommended daily sodium intake varies depending on factors like age and health conditions. For many adolescents, the recommended limit for sodium intake might differ from the specified 3,000 milligrams per day.
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