A nurse is assessing a toddler who has infective endocarditis. Which of the following findings should the nurse expect?

A. Place the child in a room with bright fluorescent lighting.

This option is not appropriate because bright fluorescent lighting can be uncomfortable and potentially aggravate symptoms such as headache or sensitivity to light, which are common after a head injury. Therefore, it is not included in the plan of care.

B. Initiate seizure precautions for the child.

This intervention is appropriate because children with head injuries are at an increased risk of seizures. Seizure precautions may include ensuring a safe environment, such as padding the sides of the bed, removing any objects that could cause harm during a seizure, and closely monitoring the child's neurological status for signs of seizure activity.

C. Use the COMFORT scale to rate the child's pain.

While assessing and managing pain is important, the COMFORT scale may not be the most appropriate tool for evaluating pain in a child with a head injury. The nurse should use a pain assessment tool that is specifically designed for pediatric patients and is suitable for assessing pain in children with head injuries.

D. Suction the child's nares to determine the presence of fluid.

Suctioning the child's nares may be indicated if there are concerns about airway patency or respiratory secretions. However, it is not a routine intervention for all children with head injuries. The nurse should assess the child's respiratory status and use suctioning only if necessary based on clinical findings.

A. Initiate antibiotic therapy for the child.

This is the priority action. Bacterial meningitis is a medical emergency, and prompt administration of antibiotics is crucial to treat the infection and prevent further complications. Therefore, the nurse should initiate antibiotic therapy as soon as possible after obtaining appropriate cultures.

B. Minimize the child's environmental stimuli.

While reducing environmental stimuli can help decrease the child's discomfort and prevent agitation, it is not the priority action when managing bacterial meningitis. Treating the underlying infection takes precedence to prevent serious complications such as neurological damage or septic shock.

C. Place the child in a side-lying position.

Positioning the child on their side may help prevent aspiration if vomiting occurs, but it is not the priority action in the initial management of bacterial meningitis. The child's positioning can be adjusted as needed once antibiotic therapy has been initiated.

D. Administer pain medication to the child.

Pain management is important for the child's comfort, but it is not the priority action when managing bacterial meningitis. The child's pain may be addressed once antibiotic therapy has been initiated and the child's condition has stabilized.