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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
A. Decreased cardiac output in heart failure can lead to poor perfusion of the extremities, resulting in cool skin and decreased urine output due to reduced renal perfusion and impaired kidney function.
D. Poor feeding is often observed due to increased respiratory effort, tachypnea, and fatigue associated with heart failure. Additionally, infants may exhibit failure to thrive or inadequate weight gain despite increased caloric intake due to metabolic demands and inefficient utilization of nutrients.
E. Tachypnea and respiratory distress occur due to pulmonary congestion and increased respiratory effort in response to heart failure. Infants may exhibit signs such as nasal flaring, grunting, retractions, and cyanosis.
B. Bradycardia and hypotension are not typical manifestations of heart failure in infants. Instead, infants with heart failure often present with tachycardia (rapid heart rate) as a compensatory mechanism to maintain cardiac output. Hypotension may occur in severe cases but is not a common finding.
C. Increased appetite and excessive weight gain are not typical manifestations of heart failure in infants. Infants with heart failure often experience poor feeding and failure to thrive due to inadequate cardiac output and oxygen delivery to meet metabolic demands.
Correct Answer is ["A","B"]
Explanation
A. Humidified oxygen can help improve oxygenation and relieve respiratory distress by maintaining optimal humidity levels in the airways, which can be beneficial, especially in infants with bronchiolitis who may have increased respiratory secretions and airway inflammation.
B. Monitoring respiratory rate and oxygen saturation allows for early detection of respiratory distress and hypoxemia, which are common complications of bronchiolitis. Regular assessment helps guide interventions and ensures timely escalation of care if needed.
C. Restricting fluid intake is not typically indicated for children with bronchiolitis. In fact, maintaining adequate hydration is crucial for children with respiratory illnesses to help thin respiratory secretions and prevent dehydration.
D. Antibiotics are not routinely indicated for the treatment of bronchiolitis caused by viral pathogens. Bronchiolitis is typically caused by respiratory syncytial virus (RSV) or other viral infections, for which antibiotics are ineffective.
E. Chest physiotherapy is not routinely recommended for the management of bronchiolitis in infants and children. Bronchiolitis is primarily managed with supportive care measures such as humidified oxygen, hydration, and monitoring for respiratory distress.
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