A nurse is assessing a client who reports a severe headache and stiff neck. The nurse's assessment reveals positive Kernig's and Brudzinski's signs. Which of the following actions should the nurse perform first?

Decrease bright lights.

Initiate IV access.

Administer antibiotics.

Implement droplet precautions.

Answer and Explanation

The Correct Answer is D

Choice A reason: Decreasing bright lights is an appropriate action for a nurse to take when caring for a client who has signs of meningitis, as it helps to reduce the photophobia (sensitivity to light) and headache that are common symptoms of the condition. However, this action is not the first priority, as it does not prevent the transmission of the infection or treat the underlying cause.

Choice B reason: Initiating IV access is an appropriate action for a nurse to take when caring for a client who has signs of meningitis, as it facilitates the administration of fluids, medications, and blood products that may be needed to manage the condition. However, this action is not the first priority, as it does not prevent the transmission of the infection or treat the underlying cause.

Choice C reason: Administering antibiotics is an appropriate action for a nurse to take when caring for a client who has signs of meningitis, as it helps to treat the bacterial infection that is the most common cause of the condition. However, this action is not the first priority, as it requires a prescription from the health care provider and confirmation of the diagnosis by laboratory tests such as blood culture or cerebrospinal fluid analysis.

Choice D reason: Implementing droplet precautions is the first priority action for a nurse to take when caring for a client who has signs of meningitis, as it helps to prevent the spread of the infection to other clients and staff members. Droplet precautions are a type of isolation precautions that are used for infections that are transmitted by respiratory droplets, such as meningitis, influenza, and pertussis. Droplet precautions involve wearing a surgical mask when entering the client's room, placing the client in a private room or cohorting with other clients who have the same infection, and limiting visitors and staff contact with the client.

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Correct Answer is B

Explanation

Choice A reason: Performing carotid massage is not an appropriate action for a nurse to take when a client has signs of a stroke, as it may worsen the condition or cause complications. Carotid massage is a technique that involves applying pressure to the carotid artery in the neck to stimulate the vagus nerve and slow down the heart rate. It is used to treat some types of arrhythmias, such as supraventricular tachycardia. However, carotid massage may dislodge a blood clot or plaque from the carotid artery and cause an embolic stroke, which is a type of ischemic stroke that occurs when a blood clot travels to the brain and blocks a blood vessel. Carotid massage may also cause bradycardia, hypotension, or syncope, which can reduce the blood flow to the brain and worsen the ischemic damage.

Choice B reason: Calling for help is an appropriate action for a nurse to take when a client has signs of a stroke, as it initiates the emergency response and allows for prompt evaluation and treatment. Stroke is a medical emergency that occurs when the blood supply to a part of the brain is interrupted, causing brain cells to die. The sooner the stroke is recognized and treated, the better the chances of survival and recovery. Therefore, the nurse should call for help as soon as possible and activate the stroke protocol in the facility.

Choice C reason: Providing the client with water to test the gag reflex is not an appropriate action for a nurse to take when a client has signs of a stroke, as it may cause aspiration or choking. A gag reflex is an involuntary contraction of the throat muscles that prevents foreign objects from entering the airway. It is tested by touching the back of the throat with a tongue depressor or a cotton swab. However, this test is not indicated in a client who has signs of a stroke, as it may trigger vomiting or coughing, which can increase intracranial pressure or cause bleeding. Moreover, giving water to a client who has signs of a stroke may be dangerous, as they may have dysphagia (difficulty swallowing) or facial weakness, which can impair their ability to swallow safely and increase the risk of aspiration pneumonia.

Choice D reason: Administering thrombolytics is not an appropriate action for a nurse to take when a client has signs of a stroke, as it may be contraindicated or harmful depending on the type and timing of the stroke. Thrombolytics are medications that dissolve blood clots and restore blood flow. They are used to treat ischemic stroke, which is caused by a blood clot that blocks a blood vessel in the brain. However, thrombolytics are not effective for hemorrhagic stroke, which is caused by bleeding into or around the brain. In fact, thrombolytics may worsen hemorrhagic stroke by increasing bleeding and intracranial pressure. Therefore, thrombolytics should only be given after confirming the type of stroke by imaging tests such as computed tomography (CT) scan or magnetic resonance imaging (MRI). Thrombolytics should also be given within a specific time window after the onset of symptoms, usually within 3 to 4.5 hours, as they may lose their effectiveness or cause complications if given too late. Therefore, administering thrombolytics is not an action that a nurse can take without proper assessment and orders from the health care provider.

A. Provide total assistance with all ADLs B. Order a low-residue diet C. Encourage client to void every hour D. Instruct the client on daily muscle stretching

Correct Answer is D

Explanation

Choice A reason: Providing total assistance with all ADLs is not an intervention that should be included in the client's plan. ADLs are activities of daily living, such as bathing, dressing, eating, and toileting. Providing total assistance with all ADLs can reduce the client's independence and self-esteem, and increase their dependence and learned helplessness. The nurse should encourage and assist the client to perform as much as they can by themselves and provide partial or intermittent assistance only when needed.

Choice B reason: Ordering a low-residue diet is not an intervention that should be included in the client's plan. A low-residue diet is a type of diet that limits foods that are high in fiber or indigestible material, such as whole grains, nuts, seeds, fruits, and vegetables. A low-residue diet may be recommended for clients who have inflammatory bowel disease (IBD), diverticulitis, or bowel obstruction, as it can reduce bowel frequency and irritation. However, it is not indicated for clients who have MS, unless they have other comorbidities that require it. A balanced diet that includes adequate fiber, fluids, and nutrients is more beneficial for clients who have MS.

Choice C reason: Encouraging the client to void every hour is not an intervention that should be included in the client's plan. Voiding every hour can be inconvenient and impractical for the client, and may not address their bladder problems effectively. MS can cause bladder dysfunction, such as urinary urgency, frequency, incontinence, or retention, due to nerve damage that affects bladder control. The nurse should assess the type and severity of the bladder dysfunction, and provide appropriate interventions, such as medication, catheterization, pelvic floor exercises, or bladder training.

Choice D reason: Instructing the client on daily muscle stretching is an intervention that should be included in the client's plan. Muscle stretching is a type of exercise that involves extending or elongating a muscle or group of muscles to their full length. Muscle stretching can help prevent or relieve muscle spasticity, stiffness, pain, or contractures that may occur in clients who have MS. The nurse should teach the client how to perform muscle stretching safely and correctly, and encourage them to do it daily or as prescribed.

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