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: Delivering a urine specimen to the laboratory is not a priority task, as it does not affect the client's immediate health or safety. This task can be done later or delegated to another staff member.
Choice B reason: Feeding a client who has bilateral casts is an important task, as it helps the client meet their nutritional needs and prevents complications such as pressure ulcers. However, this task is not as urgent as monitoring blood glucose levels, as it can be done within a reasonable time frame without causing harm to the client.
Choice C reason: Performing blood glucose monitoring of a client who has a prescription for short-acting insulin is a priority task, as it determines the dosage of insulin that the client needs to receive. Insulin is a high-alert medication that can cause serious adverse effects if given incorrectly. Therefore, this task should be done first by the AP who has been trained and certified to do so.
Choice D reason: Obtaining an extra box of tissues for a client who is concerned about running out of them is a low-priority task, as it does not affect the client's physical or psychological well-being. This task can be done at any time or delegated to another staff member.
Correct Answer is D
Explanation
Choice A reason: Natural history of disease is not an approach that explains the factors that allow the reproduction and spread of infectious disease. Natural history of disease is a concept that describes the progression and outcome of disease in the absence of any intervention. It includes stages such as susceptibility, exposure, incubation, prodrome, clinical, recovery, disability, or death.
Choice B reason: Health promotion is not an approach that explains the factors that allow the reproduction and spread of infectious diseases. Health promotion is a process that enables people to increase control over and improve their health. It involves strategies such as education, advocacy, policy, or community development.
Choice C reason: Levels of prevention is not an approach that explains the factors that allow the reproduction and spread of infectious disease. Levels of prevention is a framework that classifies different types of interventions based on their timing and purpose. It includes primary prevention (before disease occurs), secondary prevention (early detection and treatment), and tertiary prevention (reducing complications and disabilities).
Choice D reason: Epidemiologic triangle is an approach that explains the factors that allow the reproduction and spread of infectious disease. Epidemiologic triangle is a model that identifies three essential components of an infectious disease: agent (the microorganism that causes the disease), host (the person or animal that is infected), and environment (the physical, biological, or social factors that influence the transmission). The interaction and balance among these components determine the occurrence and spread of an infectious disease.
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