A nurse is assisting with the care of a client who has suspected meningitis and a decrease level of consciousness. Which of the following actions should the nurse take?
Prepare the client for liver biopsy
Put the client in a protective environment
Position the client dorsal recumbent
Place the client on NPO status
The Correct Answer is D
D. The correct action would be to place the client on NPO (Nothing by Mouth) status, option D. This is because a decreased level of consciousness can increase the risk of aspiration.
A. Liver biopsy is not indicated for suspected meningitis with a decreased level of consciousness. Liver biopsy is a procedure used to obtain a sample of liver tissue for diagnostic purposes, typically to evaluate liver function or diagnose liver diseases.
B. A protective environment (option B) is more related to immunocompromised patients. In the case of decreased level of consciousness, preventing aspiration is key.
C. Dorsal recumbent position refers to lying on the back with the knees flexed. While this position may be suitable for certain medical procedures or examinations, it is not specifically indicated for a client with suspected meningitis and a decreased level of consciousness.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This is a common postictal manifestation after a generalized tonic-clonic seizure. Following the intense muscle activity and convulsions during the seizure, the child may experience exhaustion and feel sleepy. The postictal state often involves a period of drowsiness or even brief loss of consciousness.
B. Restlessness is less likely to be observed immediately after a generalized tonic-clonic seizure. Instead, the child is more likely to exhibit fatigue and lethargy as the body recovers from the seizure activity.
C. Anxiety may occur during or immediately after the seizure due to the sudden and frightening nature of the event. However, in the postictal period, anxiety typically diminishes as the child becomes more oriented and aware of their surroundings.
D. Nausea is not a typical postictal manifestation after a generalized tonic-clonic seizure. While some individuals may experience nausea or vomiting during the seizure (ictal phase), it is less common in the postictal period.
Correct Answer is D
Explanation
D. Suctioning equipment and oxygen are essential items to have at the bedside for seizure precautions. Seizures can sometimes be associated with airway compromise, excessive secretions, or respiratory distress. Having suctioning equipment readily available allows for prompt removal of oral or airway secretions if necessary. Oxygen may be needed to support oxygenation during or after a seizure, especially if there are concerns about respiratory depression or hypoxemia.
A. A tracheotomy set is not typically needed at the bedside for seizure precautions. Tracheotomy sets are used in emergency situations to establish a surgical airway if there is a severe airway obstruction or respiratory distress.
B. An emergency cart contains essential supplies and medications needed for emergency situations, including resuscitation equipment, medications, and supplies for managing various medical emergencies. However, the cart is not placed bedside.
C. A padded tongue blade is not typically needed at the bedside for seizure precautions. Tongue blades are sometimes used during airway management to help visualize and manipulate the tongue, but padded tongue blades are not routinely included in seizure precautions.
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