A nurse is caring for a newly admitted client who has bacterial meningitis. Which of the following actions should the nurse take?

Monitor the client for hypoglycemia.

Perform range-of-motion exercises once per shift

Place the client in high-Fowler's position.

Implement seizure precautions.

Answer and Explanation

The Correct Answer is D

Rationale:

A. Monitor the client for hypoglycemia: Hypoglycemia is not a common complication of bacterial meningitis. More relevant concerns include increased intracranial pressure, fever, and potential neurological damage, rather than altered glucose metabolism.

B. Perform range-of-motion exercises once per shift: While maintaining mobility is important, this is not a priority during the acute phase of bacterial meningitis. The client may be photophobic, confused, or in too much discomfort for routine exercises early in treatment.

C. Place the client in high-Fowler's position: High-Fowler’s can increase discomfort and may worsen meningeal irritation. A more appropriate position is 30 degrees with head midline to promote venous drainage and reduce intracranial pressure.

D. Implement seizure precautions: Seizures are a potential complication of bacterial meningitis due to inflammation, increased intracranial pressure, and irritation of the cerebral cortex. Seizure precautions are a critical safety measure in the acute phase of care.

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Correct Answer is A

Explanation

Rationale:

A. Drop the sterile gauze from 25.4 cm (10 in) above the sterile field: Dropping sterile items from a height of about 6 to 12 inches prevents contamination by keeping hands outside the sterile field and ensuring the item lands safely without touching nonsterile surfaces.

B. Hold the sterile package in his dominant hand and open the top flap of the package toward his body: The top flap should be opened away from the nurse’s body to maintain sterility and prevent the arm from crossing over the sterile field, which would risk contamination.

C. Place objects 1.27 cm (0.5 in) inside the border of the sterile field: The outer 2.5 cm (1 inch) of the sterile field is considered contaminated. Placing items only 0.5 inches inside this border would place them within the contaminated zone, risking sterile field compromise.

D. Position the bottle outside the edge of the sterile field when pouring solution into a sterile container: While the bottle should not touch the sterile field, it must be close enough to pour without splashing, and the sterile container must be inside the sterile field.

A. Limited hip abduction B. Equal leg length C. Symmetric gluteal and thigh skin folds D. Femoral head remains in the acetabulum during the Barlow maneuver

Correct Answer is A

Explanation

Rationale:

A. Limited hip abduction: Limited abduction of the hips in a 1-month-old can indicate developmental dysplasia of the hip (DDH). This finding warrants further evaluation, such as ultrasound imaging, to rule out structural abnormalities and initiate early treatment if needed.

B. Equal leg length: Equal leg length is a normal finding and does not require intervention. Leg length discrepancies are more concerning and often associated with hip dislocation or other musculoskeletal conditions.

C. Symmetric gluteal and thigh skin folds: Symmetry in the gluteal and thigh folds is a reassuring sign that typically rules out DDH. Asymmetry would be more suggestive of a hip abnormality requiring follow-up.

D. Femoral head remains in the acetabulum during the Barlow maneuver: This is a normal finding. The Barlow test assesses for hip instability, and if the femoral head remains stable within the socket, no further evaluation is needed.

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A nurse is caring for a newly admitted client who has bacterial meningitis. Which of the following actions should the nurse take?

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