A nurse in the emergency department is evaluating a young adult client for bacterial meningitis. Which of the following actions should the nurse take as part of the focused assessment?

Tap the client's facial nerve and note any facial twitching.

Strike the client's patellar tendon with a percussion hammer and note any increase in response.

Gently elevate the client's head and note any nuchal rigidity.

Run a tongue blade on the outside of the client's sole and note any flaring of the toes.

Answer and Explanation

The Correct Answer is C

Choice A reason: Tapping the client's facial nerve and noting any facial twitching is not a specific assessment for bacterial meningitis. This action is more related to evaluating facial nerve function and is not typically used to diagnose meningitis.

Choice B reason: Striking the client's patellar tendon with a percussion hammer and noting any increase in response is a test for reflexes, which may or may not be altered in bacterial meningitis. An increased response can be seen in various neurological conditions and is not specific to meningitis.

Choice C reason: Gently elevating the client's head and noting any nuchal rigidity is a key part of the focused assessment for bacterial meningitis. Nuchal rigidity, or stiffness of the neck, is a classic sign of meningitis and is assessed by gently lifting the head and attempting to move the chin toward the chest. If the client resists due to pain or stiffness, this could indicate nuchal rigidity associated with meningitis.

Choice D reason: Running a tongue blade on the outside of the client's sole and noting any flaring of the toes, known as the Babinski sign, is used to assess for central nervous system lesions and is not specific to meningitis. While it can be part of a neurological assessment, it does not specifically indicate bacterial meningitis.

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Correct Answer is D

Explanation

Choice A reason : Changing the transparent membrane dressing daily is not necessary unless it's soiled or compromised. The dressing is typically changed every 7 days or per institutional policy to reduce the risk of infection.

Choice B reason: Using a non-coring needle is not applicable for PICC lines as they are designed for use with a luer-lock syringe for medication administration and flushing.

Choice C reason : Maintaining a continuous IV infusion is not required for a PICC line unless clinically indicated. Intermittent use is common for medication administration, and the line should be flushed before and after use to maintain patency.

Choice D reason : Flushing the catheter with a 0.9% sodium chloride solution after each use is the correct action. This helps to maintain catheter patency and prevent occlusion.

A. Droplet precautions B. Standard precautions C. Airborne precautions D. Contact precautions

Correct Answer is B

Explanation

Choice A reason: Droplet precautions are used for diseases that are transmitted through large respiratory droplets produced by coughing, sneezing, or talking. AIDS, caused by the Human Immunodeficiency Virus (HIV), is not transmitted through respiratory droplets, so droplet precautions are not necessary for a client with AIDS.

Choice B reason: Standard precautions are the primary strategy for the prevention of infection transmission and apply to all patients receiving care in hospitals, regardless of their diagnosis or presumed infection status. These precautions include hand hygiene, the use of personal protective equipment (PPE) like gloves and gowns, and safe injection practices. Since HIV/AIDS can be transmitted through blood and certain body fluids, standard precautions are essential when caring for clients with AIDS.

Choice C reason: Airborne precautions are used for diseases that are transmitted by small droplet nuclei that remain suspended in the air and can be widely dispersed by air currents within a room or over a long distance. HIV/AIDS is not transmitted through the airborne route, so airborne precautions are not indicated for clients with AIDS.

Choice D reason: Contact precautions are used for infections that are spread by direct contact with the patient or indirect contact with surfaces or patient care items. While HIV can be present in body fluids, it is not easily transmitted through casual contact. Therefore, contact precautions are not specifically required for clients with AIDS unless they have other conditions that warrant such precautions.

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A nurse in the emergency department is evaluating a young adult client for bacterial meningitis. Which of the following actions should the nurse take as part of the focused assessment?

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