A nurse is planning care for a 6-year-old child who has bacterial meningitis. Which of the following nursing interventions is unnecessary in the client's plan of care?

Measure head circumference every shift

Admit the client to a private room

Place the client in a semi-Fowler's position

Implement seizure precautions

Answer and Explanation

The Correct Answer is A

A. While monitoring for increased intracranial pressure is important, measuring head circumference every shift may not be necessary unless there is a specific indication or change in the child's condition.

B. Admitting the child to a private room is necessary to reduce the risk of spreading the infection to others.

C. Placing the child in a semi-Fowler's position can help reduce intracranial pressure and promote comfort.

D. Implementing seizure precautions is important, as children with bacterial meningitis are at risk for seizures.

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Correct Answer is B

Explanation

A. A respiratory rate of 20/min is within the normal range, and while it should be monitored, it is not the priority in this case.

B. Blood pressure is a critical indicator of perfusion and can be affected by internal bleeding or other serious injuries. A low blood pressure may suggest significant blood loss and is the priority in assessing for shock.

C. A heart rate of 72/min is within the normal range for an adolescent. While it should be monitored, it is not the immediate priority.

D. Abdominal pain is a subjective measure and, while important, may not accurately reflect the severity of internal injuries. The priority is to assess the hemodynamic stability, as indicated by blood pressure.

A. "My son might have nausea and vomiting with hypoglycemia." B. "The onset of low blood glucose usually occurs slowly." C. "My son might complain of feeling shaky when he has a low blood glucose level." D. "Sweating can occur with hyperglycemia."

Correct Answer is C

Explanation

A. Nausea and vomiting are more commonly associated with hyperglycemia or diabetic ketoacidosis, not hypoglycemia.

B. The onset of low blood glucose usually occurs quickly, not slowly.

C. Feeling shaky is a common symptom of hypoglycemia, and the parents' recognition of this symptom is indicative of an understanding of the teaching.

D. Sweating is also a symptom of hypoglycemia, not hyperglycemia.

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A nurse is planning care for a 6-year-old child who has bacterial meningitis. Which of the following nursing interventions is unnecessary in the client's plan of care?

Nursing Test Bank

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