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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "My son might complain of feeling shaky when he has a low blood glucose level."
Explanation: Correct Choice. Shaking or feeling shaky is a common symptom of low blood glucose levels, also known as hypoglycemia. When blood sugar drops too low, the body releases adrenaline, causing shaking or trembling. This response is indicative of an understanding of hypoglycemia symptoms.
B. "My son might have nausea and vomiting with hypoglycemia."
Explanation: Nausea and vomiting are not typical symptoms of hypoglycemia (low blood sugar). They are more commonly associated with hyperglycemia (high blood sugar) or other conditions. This statement is not accurate in the context of hypoglycemia.
C. "Sweating can occur with hyperglycemia."
Explanation: Sweating is more commonly associated with hypoglycemia (low blood sugar) rather than hyperglycemia (high blood sugar). When blood sugar levels drop too low, the body can respond with sweating as part of the adrenaline release. Sweating is not a typical symptom of hyperglycemia.
D. "The onset of low blood glucose usually occurs slowly."
Explanation: The onset of low blood glucose (hypoglycemia) can vary. It can occur suddenly, especially if the individual takes too much insulin or diabetes medication, leading to a rapid drop in blood sugar. The correct understanding is that the onset of low blood glucose can be rapid and not always slow.
Correct Answer is C
Explanation
A. Always infantize the child
Incorrect Explanation: "Infantizing" a child with a growth hormone deficiency is not a relevant or appropriate approach.
Explanation: Growth hormone deficiency is a medical condition that affects a child's growth. Treating the child as an infant could potentially have negative psychological and social effects. It's important to provide appropriate support and understanding without treating the child differently due to their medical condition.
B. Monitor for leukemia
Incorrect Explanation: Monitoring for leukemia is not directly related to growth hormone deficiency.
Explanation: Growth hormone deficiency primarily affects a child's growth and development due to inadequate production of growth hormone. While there might be certain health concerns associated with the condition, monitoring for leukemia is not a common aspect of managing growth hormone deficiency.
C. Help the parents set realistic goals based on the child's age and abilities
Correct Explanation: This is an important aspect to include in teaching.
Explanation: When a child is diagnosed with growth hormone deficiency, it's crucial for parents to set realistic expectations regarding their child's growth. Growth hormone therapy can help, but it's essential to understand that the child's growth might still differ from their peers. Setting realistic goals based on the child's age and abilities can help manage expectations and provide appropriate support.
D. This illness is only seen in males
Incorrect Explanation: Growth hormone deficiency is not limited to males.
Explanation: Growth hormone deficiency can affect individuals of any gender. It is not exclusive to males. The condition results from insufficient production of growth hormone by the pituitary gland, and it can occur in both males and females.
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