A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority?
Document intake and output.
Administer antibiotics when available
Reduce environmental stimuli
Maintain seizure precaution
The Correct Answer is B
A) Document intake and output:
Documenting intake and output is an important nursing task, but it is not the top priority in a suspected case of bacterial meningitis. Timely administration of antibiotics to treat the infection takes precedence over documentation of intake and output.
B) Administer antibiotics when available.
Explanation:
Bacterial meningitis is a serious and potentially life-threatening infection of the membranes covering the brain and spinal cord. Rapid administration of antibiotics is crucial to effectively treat the infection and prevent its spread. Delay in antibiotic administration can lead to worsening symptoms and complications. Therefore, getting the appropriate antibiotics to the child as soon as they are available is the nurse's priority.
C) Reduce environmental stimuli:
Reducing environmental stimuli can be helpful in managing symptoms and providing comfort to the child with meningitis, but it is not the priority action. The immediate concern in a suspected case of bacterial meningitis is to treat the infection.
D) Maintain seizure precaution:
While maintaining seizure precautions is important, especially if the child has a history of seizures, it is not the top priority in a suspected case of bacterial meningitis. Administering antibiotics to treat the infection and prevent its progression is the primary concern.
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Related Questions
Correct Answer is D
Explanation
A. Assess the bowel sounds:
Bowel sounds are not directly related to the assessment of ascites. Bowel sounds are more relevant in assessing gastrointestinal function and peristalsis. While bowel changes could potentially be a sign of complications, monitoring abdominal girth is more specific to tracking ascites.
B. Frequently ambulate child:
While ambulation is important for overall health, it's not a direct assessment method for monitoring ascites. Ambulating a child might have benefits, but it won't provide specific information about the presence or progression of ascites.
C. Weigh child weekly:
Weekly weighing can provide some information about overall fluid balance, but it might not be as sensitive as measuring abdominal girth when it comes to detecting changes in ascites. Additionally, monitoring weight alone might not give insight into the distribution of fluid in the abdominal cavity.
D. Monitor and measure the abdominal girth.
Explanation: The presence of ascites (accumulation of fluid in the abdominal cavity) in a child with nephrotic syndrome could indicate worsening kidney function and fluid balance. Monitoring and measuring the abdominal girth is a reliable way to assess changes in the amount of fluid accumulation over time. An increase in abdominal girth could suggest a worsening condition.
Correct Answer is C
Explanation
A. "We worry about surgery. Do you think we should investigate direct donation of blood?"
Explanation: This statement doesn't show a clear understanding of nephrotic syndrome. Nephrotic syndrome is a kidney disorder that involves the kidneys' ability to filter blood, but it doesn't typically involve blood donation or surgery related to that. Direct donation of blood is not relevant to the treatment or management of nephrotic syndrome.
B. "We'll have to encourage lots of liquids. Did you say about Biters per day?"
Explanation: This statement suggests a misunderstanding of nephrotic syndrome and its management. Encouraging lots of liquids is generally not a primary concern in nephrotic syndrome. In fact, excess fluid intake might be counterproductive, as it could worsen edema (swelling) that often occurs with this condition. Additionally, the term "Biters per day" doesn't seem relevant to nephrotic syndrome or its management.
C. "My child really likes chips and bologna. I guess we will have to find something else."
Explanation: This statement indicates an understanding of dietary considerations related to nephrotic syndrome. Nephrotic syndrome involves protein loss through the urine, which can lead to low protein levels in the blood. To address this, dietary changes are often recommended to include foods rich in protein. Avoiding high-sodium foods like chips and bologna is also important, as excessive sodium intake can contribute to fluid retention and worsen edema.
D. "We understand the need for antibiotics, hope they can be given orally."
Explanation: This statement doesn't relate to nephrotic syndrome or its management. Nephrotic syndrome primarily involves issues with kidney function and protein loss, and antibiotics are not a standard treatment for this condition. Antibiotics are used to treat infections, which can sometimes be a complication of nephrotic syndrome due to the immune system's vulnerability, but the statement doesn't focus on the understanding of the disease itself.
Correct Answer: C. "My child really likes chips and bologna. I guess we will have to find something else."
Explanation: This statement shows an understanding of the dietary changes needed for a child with nephrotic syndrome. It acknowledges the importance of adjusting the child's diet to include protein-rich foods and avoid high-sodium options, which aligns with the nutritional considerations for managing nephrotic syndrome.
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