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 C
Explanation
Choice A reason: Repeat dose in 1 hour for unrelieved headache. This instruction is incorrect because sumatriptan should not be taken more than twice in 24 hours. Taking too much sumatriptan can cause serious side effects, such as high blood pressure, stroke, or heart problems.
Choice B reason: Chew the tablet well before swallowing. This instruction is incorrect because sumatriptan tablets should be swallowed whole with water. Chewing the tablet may affect its absorption and effectiveness.
Choice C reason: If you experience chest pain, call your physician immediately. This instruction is correct because chest pain is a serious and potentially life-threatening side effect of sumatriptan. Chest pain may indicate a heart attack or coronary artery spasm, which require immediate medical attention.
Choice D reason: Take daily to prevent headaches. This instruction is incorrect because sumatriptan is not a preventive medication for migraines. It is only used to treat acute migraine attacks when they occur. Taking sumatriptan daily can cause rebound headaches, which are worse and more frequent than the original ones.
Correct Answer is A
Explanation
Choice A reason: "Move objects away from the client." This instruction should be included in the teaching. It is a safety measure that can prevent injury or harm to the client during a seizure. Moving objects away from the client can create more space and avoid contact with sharp, hard, or hot items.
Choice B reason: "Restrain the client." This instruction should not be included in the teaching. It is a harmful action that can worsen or prolong the seizure. Restraining the client can interfere with their natural movements, cause pain or discomfort, or damage their muscles or joints.
Choice C reason: "Place the client on his back." This instruction should not be included in the teaching. It is a dangerous position that can compromise the client's airway and breathing. Placing the client on his back can increase the risk of choking, aspiration, or suffocation.
Choice D reason: "Insert a padded tongue blade into the client's mouth." This instruction should not be included in the teaching. It is an outdated and ineffective practice that can cause more harm than good. Inserting a padded tongue blade into the client's mouth can damage their teeth, gums, tongue, or lips, or block their airway. Contrary to popular belief, it is impossible for a person to swallow their tongue during a seizure.
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