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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Sore throat: A sore throat may indicate agranulocytosis, a serious adverse effect of clozapine that results in dangerously low white blood cell counts. Early signs include fever, sore throat, and malaise. This requires immediate reporting and evaluation with a complete blood count.
B. Tinnitus: Tinnitus is not a known or common adverse effect of clozapine. While bothersome, it is not typically associated with the hematologic or metabolic risks posed by this antipsychotic medication.
C. Rhinitis: Although rhinitis can occur with many medications, it is not a serious or expected side effect of clozapine requiring urgent attention. Mild nasal symptoms are usually self-limiting and not indicative of life-threatening complications.
D. Headache: Headaches are common and nonspecific symptoms that may result from various causes. Unless severe or persistent, they do not typically indicate a dangerous reaction to clozapine and are not prioritized over signs of infection.
Correct Answer is C
Explanation
Rationale:
A. Temperature 36.8° C (98° F): This temperature is within the normal range and does not suggest a current or impending infection. It indicates stable thermoregulation in the postoperative period.
B. White blood cell count 8,000/mm³ (5,000 to 10,000/mm³): This WBC count falls within the normal reference range and does not reflect infection or inflammation. No abnormal immune response is indicated by this result.
C. Body mass index of 32: A BMI over 30 is classified as obesity, which increases the risk of poor wound healing and surgical site infections. Excess adipose tissue can impair circulation, oxygenation, and immune response at the wound site.
D. Blood glucose 90 mg/dL (74 to 106 mg/dL): This is a normal fasting glucose level and does not contribute to infection risk. Well-controlled glucose levels are favorable for wound healing and immune function.
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