A nurse is contributing to the plan of care for a client who has viral meningitis. Which of the following interventions should the nurse recommend?
Measure the client's intake and output every 8 hr.
Dim the lighting in the client's room.
Monitor the client's temperature every 6 hr.
Initiate contact precautions for the client.
The Correct Answer is B
Choice A Reason:
Measuring the client's intake and output every 8 hours is a general nursing intervention but might not be specifically pertinent to managing viral meningitis.
Choice B Reason:
Dim the lighting in the client's room is correct. Meningitis often causes sensitivity to light (photophobia) due to the inflammation of the meninges surrounding the brain and spinal cord. Dimming the lighting in the client's room helps reduce discomfort and sensitivity to light, which is a common symptom of meningitis.
Choice C Reason:
Monitoring the client's temperature every 6 hours is a routine nursing practice, but in viral meningitis, more frequent temperature monitoring might be necessary, especially if the client shows signs of fever or instability.
Choice D Reason:
Initiating contact precautions for viral meningitis is not typically necessary because it's usually transmitted through respiratory secretions. Standard precautions for infection control, including proper hand hygiene, are usually sufficient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Administering a prescribed oral dose of trazodone to the client is correct. Trazodone is sometimes used to manage agitation in patients with Alzheimer's disease, as it has calming effects and can help reduce agitation and anxiety. However, the use of any medication should be based on the client's individualized treatment plan and prescribed by a healthcare provider.
Choice B Reason:
Encouraging ambulation might not be suitable if the client is agitated, as it could potentially escalate the situation or increase the risk of falls or injury. Safety should be a priority, and ambulation might not be advisable during a state of agitation.
Choice C Reason:
Isolating the client in their room is incorrect. Isolating the client might increase feelings of confusion, fear, or distress, potentially worsening the agitation. It's important to engage and support the client rather than isolate them, which can be distressing for someone with Alzheimer's disease.
Choice D Reason:
Applying bilateral wrist restraints to the client is incorrect. The use of restraints should only be considered as a last resort when all other measures have failed and when there's an immediate risk of harm to the client or others. Restraints can be physically and psychologically harmful, leading to increased agitation, anxiety, and potential injury. They should be used only under strict guidelines and with proper authorization when all other interventions have been exhausted.
Correct Answer is C
Explanation
Choice A Reason:
Nerve damage is incorrect. Nerve damage typically presents with symptoms such as altered sensation, numbness, tingling, or shooting pain along the path of the nerve. The symptoms described in the scenario are more indicative of localized inflammation rather than nerve-related issues.
Choice B Reason:
Infection is incorrect. Infection at the insertion site can manifest with redness, warmth, tenderness, and possibly purulent drainage. While infection is a potential complication of IV therapy, the symptoms described might indicate a different issue.
Choice C Reason:
Infiltration is correct. Infiltration occurs when the IV fluid leaks into the surrounding tissues. Symptoms often include swelling, coolness, and tenderness at the site due to the fluid accumulating in the tissue instead of going into the vein. These symptoms align with the description provided.
Choice D Reason:
Phlebitis is incorrect. Phlebitis is the inflammation of a vein, typically presenting with redness, warmth, and tenderness along the vein's path.
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