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.
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Related Questions
Correct Answer is C
Explanation
Choice A reason: Administering an antipyretic is not the next action that the nurse should initiate. An antipyretic is a medication that lowers fever, which is a common symptom of meningococcal meningitis. However, fever is not a life-threatening condition, and it may have some beneficial effects on fighting infection. The nurse should first prioritize other actions that are more urgent or critical for the client's safety and outcome.
Choice B reason: Decreasing environmental stimuli is not the next action that the nurse should initiate. Decreasing environmental stimuli is a nursing intervention that can help reduce agitation, confusion, or seizures in clients with meningococcal meningitis. However, it is not an immediate or essential action, and it may not be effective if the client's condition worsens or progresses to coma.
Choice C reason: Assessing the cranial nerves is the next action that the nurse should initiate. Cranial nerve assessment is a neurological examination that evaluates the function of 12 pairs of nerves that originate from the brainstem and control various sensory and motor functions, such as vision, hearing, smell, taste, facial expression, eye movement, swallowing, speech, and balance. Meningococcal meningitis is an inflammation of the meninges, which are the membranes that cover and protect the brain and spinal cord. Meningeal inflammation can compress or damage the cranial nerves, causing various signs and symptoms, such as headache, photophobia, diplopia, facial palsy, dysphagia, dysarthria, or nystagmus. Assessing the cranial nerves can help detect any neurological deficits or complications early, and guide appropriate interventions or referrals.
Choice D reason: Completing a vascular assessment is not the next action that the nurse should initiate. A vascular assessment is a physical examination that evaluates the blood flow and circulation in different parts of the body, such as the arms, legs, abdomen, or neck. It may include checking pulses, blood pressure, capillary refill, skin color, temperature, or edema. A vascular assessment may be relevant for some clients with meningococcal meningitis who develop septic shock or disseminated intravascular coagulation (DIC), which are serious conditions that affect blood vessels and clotting factors. However, these are not common or early manifestations of meningococcal meningitis, and they require more advanced or specialized assessments and treatments.
Correct Answer is A
Explanation
Choice A reason: Monitoring vital signs and neurological status frequently is a priority intervention for a client who has experienced a hemorrhagic stroke, as it helps to detect any changes in the client's condition and guide appropriate treatment. Hemorrhagic stroke is a medical emergency that occurs when a blood vessel in the brain ruptures and causes bleeding into the brain tissue. This can lead to increased intracranial pressure, cerebral edema, and brain damage. Therefore, the nurse should monitor the client's blood pressure, pulse, respiration, temperature, level of consciousness, pupil reaction, motor function, and sensory function frequently and report any abnormalities to the health care provider.
Choice B reason: Maintaining strict bed rest to minimize cerebral blood flow is not a priority intervention for a client who has experienced a hemorrhagic stroke, as it may not prevent further bleeding or improve the client's outcome. In fact, strict bed rest may increase the risk of complications such as deep vein thrombosis, pulmonary embolism, pneumonia, pressure ulcers, and muscle atrophy. The nurse should follow the health care provider's orders regarding the client's activity level and position. The nurse should also provide adequate hydration, nutrition, skincare, and comfort measures to the client.
Choice C reason: Administering anticoagulant medications as prescribed is not a priority intervention for a client who has experienced a hemorrhagic stroke, as it may worsen the bleeding and increase the risk of intracranial hemorrhage. Anticoagulant medications are used to prevent or treat ischemic stroke, which is caused by a blood clot that blocks a blood vessel in the brain. However, anticoagulant medications are contraindicated in hemorrhagic stroke, as they interfere with the blood's ability to clot and stop the bleeding. The nurse should avoid giving any medications that may affect coagulation or platelet function to the client unless ordered by the health care provider.
Choice D reason: Assisting the client with active range of motion exercises is not a priority intervention for a client who has experienced a hemorrhagic stroke, as it may not improve the client's neurological function or prevent complications. Active range of motion exercises are performed by the client with or without assistance from the nurse to maintain joint mobility and muscle strength. However, these exercises are not indicated in the acute phase of hemorrhagic stroke, as they may increase intracranial pressure or cause pain or discomfort to the client. The nurse should consult with the physical therapist before initiating any exercise program for the client.
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