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: 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.

A. "I may experience urinary incontinence." B. "I should not exercise because this may trigger an exacerbation." C. "I should alternate the eye patch every other day to help with the double vision." D. "I may experience visual disturbances." E. "I need to check the water temperature before I take a bath."

Correct Answer is ["B","C"]

Explanation

Choice A reason: "I may experience urinary incontinence." This statement does not indicate the need for additional teaching. It is a correct statement that reflects an understanding of one of the possible symptoms of MS. Urinary incontinence is caused by nerve damage that affects bladder control.

Choice B reason: "I should not exercise because this may trigger an exacerbation." This statement indicates the need for additional teaching. It is an incorrect statement that reflects a misconception about exercise and MS. Exercise does not cause or worsen MS relapses but rather has many benefits for people with MS, such as improving muscle strength, balance, mobility, mood, and quality of life.

Choice C reason: "I should alternate the eye patch every other day to help with the double vision." This statement indicates the need for additional teaching. It is an incorrect statement that reflects a misunderstanding of how to manage double vision, which is another possible symptom of MS. Alternating the eye patch every other day does not help with double vision, but rather may cause eye fatigue or confusion. The correct way to use an eye patch is to wear it on one eye only when needed, such as when reading or driving.

Choice D reason: "I may experience visual disturbances." This statement does not indicate the need for additional teaching. It is a correct statement that reflects an awareness of another possible symptom of MS. Visual disturbances may include blurred vision, loss of color vision, pain in one eye, or partial or complete blindness.

Choice E reason: "I need to check the water temperature before I take a bath." This statement does not indicate the need for additional teaching. It is a correct statement that reflects a precaution that people with MS should take. Checking the water temperature before taking a bath can prevent burns or scalds, as some people with MS may have reduced sensation or numbness in their skin.

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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?

Nursing Test Bank

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