A nurse is assessing a client who reports severe headache and a stiff neck. The nurse's assessment reveals positive Kernig's signs. Which of the following actions should the nurse perform first?
Administer Antibiotics
Decrease bright lights
Initiate IV access
Implement droplet precautions
The Correct Answer is D
A. Administering antibiotics is crucial but not the immediate first action.
B. Decreasing bright lights can help with comfort but is not the first priority.
C. Initiating IV access is important for medication administration but not the first action.
D. Implementing droplet precautions is the first action to prevent the spread of potentially contagious bacterial meningitis until the causative organism is identified.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Administering antibiotics is crucial but not the immediate first action.
B. Decreasing bright lights can help with comfort but is not the first priority.
C. Initiating IV access is important for medication administration but not the first action.
D. Implementing droplet precautions is the first action to prevent the spread of potentially contagious bacterial meningitis until the causative organism is identified.
Correct Answer is C
Explanation
A. Severe headache and neck stiffness are more indicative of meningitis, not Guillain-Barré syndrome.
B. Chest pain and difficulty breathing can occur in advanced stages but are not the initial common symptoms.
C. Muscle weakness and paralysis that start in the legs and spread to the upper body are hallmark symptoms of Guillain-Barré syndrome.
D. Blurred vision and eye pain are not typically associated with Guillain-Barré syndrome.
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