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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Plantar flexion is the movement of the foot that points the toes downward. It is not a test for gait, but rather a test for muscle strength and nerve function in the lower leg.
Choice B reason: Romberg is a test for balance and coordination that involves asking the client to stand with their feet together and arms at their sides, first with their eyes open and then with their eyes closed. If the client sways or falls when their eyes are closed, it indicates a problem with their proprioception, which is the sense of position and movement of the body. Ataxia is a condition that affects proprioception and causes impaired gait, so Romberg is an appropriate test for it.
Choice C reason: Achilles reflex is the contraction of the calf muscle when the Achilles tendon is tapped. It is not a test for gait, but rather a test for spinal cord function and nerve damage in the lower leg.
Choice D reason: Patellar reflex is the extension of the lower leg when the patellar tendon is tapped. It is not a test for gait, but rather a test for spinal cord function and nerve damage in the upper leg.
Correct Answer is B
Explanation
Choice A reason: Advances in surgical techniques and procedures have improved the outcomes of many patients, but they are not the main factor for the increase in life expectancy. Surgical interventions are often costly, risky, and inaccessible to many people, especially in developing countries.
Choice B reason: Sanitation and other public health activities have had a significant impact on reducing mortality from infectious diseases, such as cholera, typhoid, and tuberculosis. These activities include providing safe water, improving hygiene, promoting vaccination, and controlling vector-borne diseases. Sanitation and public health measures are relatively low-cost, effective, and preventive strategies that can benefit large populations.
Choice C reason: Technology increases in the field of medical laboratory research have contributed to the diagnosis and treatment of many diseases, such as cancer, diabetes, and genetic disorders. However, these technologies are often expensive, complex, and dependent on specialized equipment and personnel. Therefore, they are not the main reason for the increase in life expectancy.
Choice D reason: The use of antibiotics to fight infections has been a major breakthrough in medicine, saving millions of lives from bacterial infections. However, antibiotics have also led to the emergence of antibiotic-resistant bacteria, which pose a serious threat to public health. Moreover, antibiotics are not effective against viral infections, such as influenza, HIV, and COVID-19. Therefore, antibiotics are not the most responsible factor for the increase in life expectancy.
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