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 C

Explanation

Choice A reason: "Diet and exercise is good for you and good for your heart." This statement is true, but it is not the appropriate nursing response. It does not address the client's concerns or provide any specific information about cardiac rehabilitation. It may also sound dismissive or patronizing to the client.

Choice B reason: "It's not unusual to feel that way at first, but once you learn the routine, you'll enjoy it." This statement is empathetic, but it is not the appropriate nursing response. It does not explain the purpose or benefits of cardiac rehabilitation. It may also sound unrealistic or optimistic to the client.

Choice C reason: "Cardiac rehabilitation cannot undo the damage to your heart, but it can help you get back to your previous level of activity safely." This statement is the appropriate nursing response. It acknowledges the client's condition and provides factual information about cardiac rehabilitation. It also emphasizes the positive outcomes of cardiac rehabilitation, such as improving physical function, reducing symptoms, and preventing further complications.

Choice D reason: "Your doctor is the expert here, and I'm sure he would only recommend what is best for you." This statement is respectful, but it is not the appropriate nursing response. It does not answer the client's question or provide any education about cardiac rehabilitation. It may also sound evasive or deferential to the client.

A. Develop a survey on teen pregnancies B. Hold a focus group to discuss immunizations C. Interview the elderly at the senior center D. Perform a windshield survey

Correct Answer is D

Explanation

Choice A reason: Developing a survey on teen pregnancies is not a priority intervention for a public health nurse who is assigned to a new community. This is a specific topic that may not be relevant or important for the whole population. A survey also requires time and resources to design, distribute, and analyze.

Choice B reason: Holding a focus group to discuss immunizations is not a priority intervention for a public health nurse who is assigned to a new community. This is a specific topic that may not be representative of the community's health needs and concerns. A focus group also requires recruitment, facilitation, and interpretation of the participants' views.

Choice C reason: Interviewing the elderly at the senior center is not a priority intervention for a public health nurse who is assigned to a new community. This is a specific group that may not reflect the diversity and characteristics of the whole population. An interview also requires consent, rapport, and recording of the responses.

Choice D reason: Performing a windshield survey is a priority intervention for a public health nurse who is assigned to a new community. This is a general method that allows the nurse to observe and assess various aspects of the environment that affect the health and well-being of the population. A windshield survey also requires minimal resources and can be done quickly and easily. A windshield survey is a method of assessing the health needs and resources of a community by driving or walking around and observing various aspects of the environment, such as housing, transportation, services, and safety. This is a priority intervention for a public health nurse who wants to get a comprehensive overview of the community and identify its strengths and weaknesses.

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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?

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