A nurse is contributing to the plan of care for a newly admitted adolescent.
A nurse is contributing to the plan of care for a newly admitted adolescent. Which of the following interventions should the nurse include?
Suction the client's airway every 2 hr.
Maintain the client's head of the bed at 30°.
Keep the client's room well lit.
Check the client's temperature every 8 hr.
The Correct Answer is B
A: Suctioning the client's airway every 2 hours is not indicated based on the provided information. The adolescent does not have a condition that compromises airway clearance, and routine suctioning can cause trauma or stimulate a vagal response, potentially leading to bradycardia.
B: Maintaining the client's head of the bed at 30° is appropriate for reducing intracranial pressure and facilitating venous drainage. The patient's symptoms of nuchal rigidity and severe headache suggest increased intracranial pressure, possibly due to meningitis, which is supported by the diagnostic results.
C: Keeping the client's room well lit is not advisable as the patient reports photophobia, which is a sensitivity to light. A well-lit room could exacerbate discomfort and pain.
D: Checking the client's temperature every 8 hours is important but not the priority intervention. The patient's condition requires more frequent monitoring due to the positive blood culture and sensitivity, indicating an active infection. More frequent temperature checks would be warranted.
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Related Questions
Correct Answer is D
Explanation
A: Introducing fruit juice at 4 months old is not recommended because infants' digestive systems are not yet ready for such foods, and it can increase the risk of tooth decay and obesity.
B: Introducing eggs at 6 months could be appropriate; however, it is not the best choice as it does not reflect the gradual introduction of new foods one at a time, which is essential to monitor for any allergic reactions or food intolerances.
C: Offering cereal with a percent of milk is not advisable for a 4-month-old infant as cow's milk should not be introduced until the child is at least 12 months old due to the risk of iron deficiency and potential allergies.
D: Offering a new food every 7 days is the correct approach as it allows parents to introduce new foods gradually and monitor the infant for any adverse reactions or allergies, which aligns with the guidelines provided by health authorities.
Correct Answer is B
Explanation
Choice A: Teaching the child to swim does not eliminate the risk of accidental drowning. While swimming skills are important, they cannot guarantee that a child will not drown, especially if they are unsupervised or encounter an unexpected situation in the water.
Choice B: An adult should remain within arm's reach of the child when near water. Constant supervision is crucial because toddlers can move quickly and may not understand the dangers of water. Being within arm's reach allows the adult to react immediately if the child is in distress.
Choice C: Most incidents of accidental drowning do not necessarily occur in ponds or lakes; they can happen in any body of water, including home swimming pools, bathtubs, and even buckets. Therefore, vigilance is required around all water sources.
Choice D: Placing a fence around a pool can help prevent accidental drowning, but it does not ensure the safety of the child. A fence is a barrier but not a substitute for active supervision. It's also important that the fence is properly maintained and secured.
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