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:
Elevate the head of the client's bed for 1 hr. after the feeding is appropriate. This action helps minimize the risk of aspiration. Elevating the head of the bed (typically at least 30 to 45 degrees) can reduce the chance of reflux and aspiration of the feeding solution into the lungs. This position should ideally be maintained for about 1 hour after the feeding to aid digestion and reduce the risk of complications.
Choice B Reason:
Administering the feeding solution at a cold temperature is inappropriate. Feeding solutions are generally administered at room temperature or slightly warmed to prevent discomfort and minimize the risk of altering the client's core body temperature. Cold temperatures can cause discomfort or cramping and might affect the absorption of the nutrients. Therefore, administering the feeding solution at a cold temperature is not recommended.
Choice C Reason:
Rotating the jejunostomy tube once per day is inappropriate. Rotating the jejunostomy tube is not typically part of routine care. Tube rotation can cause discomfort, irritation, and potential injury to the gastrointestinal tract. Tubes should be secured properly to prevent movement but not rotated unless specifically instructed by a healthcare provider for a particular reason, such as checking for proper tube placement.
Choice D Reason:
Flushing the tube with 90 ml of sterile water before and after the feeding is inappropriate.
Flushing the tube with sterile water before and after the feeding helps ensure the patency of the tube and prevents clogging. It's a standard procedure to clear the tube and maintain its function
Correct Answer is B
Explanation
Choice A Reason:
"I can take my partner outside of the room as long as they wear a mask."MRSA contact precautions typically involve limiting the spread of the bacteria. Taking the partner outside the room while wearing a mask might not be sufficient for infection control, as MRSA can spread through direct contact with surfaces. This statement might not indicate a full understanding of MRSA precautions.
Choice B Reason:
"I will wash my hands as soon as I leave the room. “Hand hygiene is a crucial component of infection control for MRSA. Washing hands with soap and water or using alcohol-based hand sanitizer after leaving the room helps prevent the spread of MRSA to oneself or others.
Choice C Reason:
"I will wear a gown when I help my partner take a bath." Wearing a gown during tasks that might involve contact with the patient's bodily fluids or surfaces that might be contaminated is recommended for MRSA precautions. This statement aligns with infection control practices.
Choice D Reason:
"I can reuse unsoiled gloves when I re-enter the room. “Reusing gloves, even if they appear unsoiled, is generally not recommended as it can contribute to the spread of MRSA. Gloves should be disposed of after each use and hands washed thoroughly.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today