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 D
Explanation
Choice A Reason:
"I will perform breast exams the day my period begins." This statement is incorrect because performing breast exams just before or during your period might not be ideal. Breasts can be more tender or swollen during this time, which could make it harder to detect any abnormalities.
Choice B Reason:
"I will perform breast exams every other month." This statement is incorrect. Regular breast self-exams are important, but doing them every other month might not be frequent enough. It's generally recommended to perform breast self-exams once a month, ideally around the same time each month, to detect any changes or abnormalities early.
Choice C Reason:
"It is common for the skin on my breasts to dimple." This statement is incorrect. Dimpling or puckering of the skin on the breasts can sometimes be a sign of an underlying issue, such as breast cancer. It's not considered a normal or common occurrence, so this statement doesn't indicate an understanding of what to look for during a breast self-exam. If a person notices skin changes like dimpling, it's recommended to seek medical advice.
Choice D Reason:
"It is common for one breast to be larger than the other." This statement reflects an understanding that breast asymmetry, where one breast is slightly larger than the other, is a common and normal occurrence.
Correct Answer is D
Explanation
Choice A Reason:
Polyuria is incorrect. Peritonitis doesn’t directly influence urine output. Polyuria (increased urine production) is more commonly associated with conditions affecting the kidneys or diabetes mellitus rather than peritonitis.
Choice B Reason:
Peripheral edema is incorrect. Peritonitis typically involves abdominal symptoms and signs rather than peripheral issues like edema. Edema can be related to heart, kidney, or circulatory system problems, but it's not a typical manifestation of peritonitis.
Choice C Reason:
Decreased respirations is incorrect. Peritonitis can cause pain and discomfort, which might affect the depth of breathing or result in shallow breathing due to guarding against abdominal pain. However, decreased respirations as a specific finding wouldn't commonly be expected in peritonitis. Pain might cause shallow breathing, but it wouldn't lead to a consistent decrease in respiratory rate.
Choice D Reason:
Absent bowel sounds is correct. Peritonitis is an inflammation of the peritoneum, the lining of the abdominal cavity. This condition often leads to the loss or significant reduction of bowel sounds due to the irritation and inflammation of the abdominal structures.
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