A nurse in the emergency room is assessing a client who was brought in following a seizure. The nurse suspects the client may have meningococcal meningitis. Assessment findings include nuchal rigidity and a petechial rash. After Implementing droplet precautions, which of the following actions should the nurse initiate next?

Complete a vascular assessment.

Assess the cranial nerves

Decrease environmental stimuli.

Administer an antipyretic.

Answer and Explanation

The Correct Answer is B

A. Complete a vascular assessment: Although meningococcal meningitis can lead to complications such as septicemia, which affects vascular status, assessing cranial nerves is more immediately pertinent. Identifying neurological deficits can provide crucial information about the extent and location of meningitis-related brain involvement.

B. Assess the cranial nerves: This is the correct action to initiate next. Meningococcal meningitis can affect the central nervous system, leading to cranial nerve involvement. Assessing the cranial nerves helps to identify any neurological deficits early, which is crucial for guiding treatment and monitoring progression.

C. Decrease environmental stimuli: While this is important for managing a patient with meningitis to prevent further neurological irritation, it is not as immediate a priority as assessing cranial nerve function to detect any neurological impairment.

D. Administer an antipyretic: Fever management is important, but it is not the next immediate priority after initiating droplet precautions. Assessing cranial nerves provides vital information about the patient's neurological status, which directly impacts immediate clinical decisions.

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Free Nursing Study Resources

Correct Answer is ["A","B","D","E"]

No explanation

A. Identify the underlying cause B. Tell the client that hallucinations are not real C. Speak slowly and clearly D. Request the assistance of physical therapy

Correct Answer is A

Explanation

Identify the underlying cause. This is correct because delirium is a reversible condition that is often caused by an underlying medical problem, such as infection, medication, or dehydration.

Identifying and treating the cause can help resolve the delirium and prevent further complications.

Tell the client that hallucinations are not real. This is incorrect because it can increase the client's anxiety and confusion. The nurse should acknowledge the client's feelings and perceptions, but not reinforce or argue with them.

Speak slowly and clearly. This is incorrect because it is not the best first action. While speaking slowly and clearly can help communicate with the client, it does not address the root cause of the delirium.

Request the assistance of physical therapy. This is incorrect because it is not relevant to the question. Physical therapy may be helpful for some clients with delirium, but it is not a priority intervention.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client reports visual disturbances followed by debilitating pain, nausea, and light sensitivity. When providing education for this client, what can the nurse include in teaching? Select all that apply (Select All that Apply.)

Correct Answer is ["A","B","D","E"]

According to the ATI video case study, Cognition: Delirium and Dementia, which of the following is the best first action for the nurse to take when caring for a client with delirium?

Correct Answer is A

Explanation

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an Indication of Increased Intracranial pressure (ICP)?

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A nurse is in a client's room when the client begins having a tonicclonic seizure. Which of the following actions should the nurse take first?

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A nurse is monitoring the vitals of a client who has a traumatic brain injury. Which of the following indicate that the client is in stage 3 of increased Intracranial pressure? Select all that apply (Select All that Apply.)