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 C
Explanation
Rationale:
A. "Placement of the catheter is confirmed by a CT scan.": Catheter placement is typically confirmed by a chest X-ray, not a CT scan, to verify correct positioning and rule out complications such as pneumothorax. CT imaging is not routine for this purpose.
B. "You will be under general anesthesia for this procedure.": Placement of a nontunneled percutaneous central line is usually done under local anesthesia with possible mild sedation. General anesthesia is not required for this relatively short and minimally invasive procedure.
C. "The provider will wear a mask while performing the procedure.": A mask, along with sterile gloves, gown, and drape, is worn to maintain sterile technique and reduce the risk of catheter-related bloodstream infections. This is standard protocol during central line insertion.
D. "Your head will be elevated as high as possible while the catheter is inserted.": The client is usually placed in the Trendelenburg position (head down) during catheter insertion to distend neck veins and reduce the risk of air embolism—not in a high head-elevated position.
Correct Answer is D
Explanation
Rationale:
A. A client who has decreased interleukin-6 levels: Interleukin-6 is a pro-inflammatory cytokine that may be elevated in depression, but its decrease is not an indicator for antidepressant use. It’s not routinely used to determine the need for antidepressant therapy in clinical practice.
B. A client who has decreased urine cortisol levels: Depression is more commonly associated with increased cortisol levels due to stress responses. Low cortisol may be seen in conditions like Addison's disease but does not typically guide antidepressant use.
C. A client who has decreased C-reactive protein levels: CRP is a nonspecific inflammatory marker. While elevated CRP has been observed in some individuals with depression, a decreased CRP level would not indicate the need for antidepressant therapy.
D. A client who has decreased serotonin levels: Low serotonin levels are closely linked to depression pathophysiology. Many antidepressants, such as SSRIs, target serotonin levels to relieve depressive symptoms, making this the most relevant indicator for antidepressant therapy.
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