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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Cold compresses may exacerbate vaso-occlusion in a client with sickle cell anemia and are not recommended.
Choice B reason:
Maintaining bed rest can help reduce the risk of hypoxemia, as it minimizes energy expenditure and oxygen demand.
Choice C reason:
Increasing oral fluid intake is important for preventing vaso-occlusive crises, so decreasing fluid intake is not a recommended intervention.
Choice D reason:
Administering meperidine for fever is not a standard intervention for sickle cell anemia. Fever during a vaso-occlusive crisis should be evaluated and treated according to the underlying cause.
Correct Answer is B
Explanation
Choice A reason:
Roseola infantum is a common viral illness in infants and young children, but it is not considered a notifiable infectious disease.
Choice B reason:
Correct. Measles is a notifiable infectious disease. This means that healthcare providers are required to report any diagnosed cases to public health authorities due to its potential for outbreaks.
Choice C reason:
Fifth disease, caused by parvovirus B19, is typically a mild viral illness in children and is not classified as a notifiable infectious disease.
Choice D reason:
Scabies is a parasitic infestation, not an infectious disease. It is caused by the Sarcoptes scabiei mite and is not considered notifiable.
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