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 A

Explanation

A. Body weight is the most reliable indicator of fluid loss in an infant. Changes in weight can reflect changes in fluid balance more accurately than other parameters.
B. Blood pressure may be affected by severe dehydration, but it is not as sensitive or specific as changes in body weight.
C. Skin integrity can be affected by dehydration, but it is not as direct a measure of fluid loss as changes in body weight.
D. Respiratory rate can be influenced by various factors, including respiratory distress, and is not as specific to fluid loss as changes in body weight.

A. Suction the nasopharynx as needed. B. Withhold fluids until the client demonstrates a gag reflex. C. Perform chest physiotherapy. D. Place a bedside humidifier at the head of the client's bed.

Correct Answer is B

Explanation

A. Suctioning the nasopharynx as needed can help maintain airway patency but does not directly prevent aspiration during the recovery period.

B. Withholding fluids until the client demonstrates a gag reflex is a standard precaution to prevent aspiration, particularly in the immediate postoperative period.

C. Chest physiotherapy is not specifically indicated for preventing aspiration in the post- tonsillectomy period.

D. Placing a bedside humidifier at the head of the client's bed is not a specific intervention for preventing aspiration after tonsillectomy. Monitoring the client's ability to swallow and the return of the gag reflex is more relevant.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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