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 C

Explanation

Rationale:

A. Make an audio recording of the adolescent's responses: Audio recordings require consent and may not be legally or ethically appropriate in suspected abuse cases. Documentation should be written, factual, and follow institutional policies and mandatory reporting laws.

B. Promise not to disclose information shared during the interview: Nurses must never promise confidentiality in suspected abuse cases, as they are mandated reporters. All disclosures of abuse must be reported to child protective services or appropriate authorities.

C. Obtain a history from both the adolescent and their caregiver: Gathering information from both parties helps identify inconsistencies and assess the situation fully. However, this should be done separately to allow the adolescent to speak freely and without coercion.

D. Use leading questions during the interview: Leading questions can influence the adolescent’s responses and compromise the integrity of the assessment. Open-ended, nonjudgmental questions are essential to support accurate and unbiased information gathering.

A. Use a powered lift to transfer the client. B. Wrap their arms under the client's axilla to transfer the client. C. Use a gait belt to transfer the client. D. Use a sliding board to transfer the client.

Correct Answer is A

Explanation

Rationale:

A. Use a powered lift to transfer the client: When a client is unable to assist and weighs significantly over standard lifting limits, a powered mechanical lift is the safest and most appropriate method. It reduces the risk of musculoskeletal injury to staff and ensures safe, controlled client movement.

B. Wrap their arms under the client's axilla to transfer the client: This manual lifting method can cause harm to both the nurse and the client. It increases the risk of shoulder injury for the client and back strain for the nurse, especially when the client is immobile and heavy.

C. Use a gait belt to transfer the client: Gait belts are used for clients who can bear some weight and assist in the transfer. Since this client cannot assist, a gait belt is insufficient and may result in injury or unsafe movement.

D. Use a sliding board to transfer the client: Sliding boards are typically used when clients have upper body strength and can assist in shifting their weight. For a fully dependent client of this size, it is not a safe or effective method without mechanical assistance.

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