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
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 C
Explanation
A. It is not possible to stop a seizure once it has started. The focus should be on ensuring the safety of the child during the seizure.
B. Restraint is not recommended during a seizure, as it can lead to injury and increased agitation.
C. Positioning the child laterally helps prevent aspiration and allows for drainage of oral secretions during a seizure.
D. Using a padded tongue blade is not necessary during a seizure and can pose a risk of injury. It is essential to protect the child's airway without inserting any objects into the mouth.
Correct Answer is D
Explanation
A. Discouraging visits from friends may contribute to social isolation, which can negatively
impact the child's psychosocial well-being. Encouraging social interactions, when appropriate, is generally beneficial.
B. While play therapy may be useful in certain situations, it may not be the primary focus for a 10-year-old child. Encouraging age-appropriate activities and interactions, including school work, is important.
C. Varying the child's schedule each day might introduce unnecessary stress and disrupt the sense of routine and stability, which is essential for psychosocial well-being.
D. Encouraging the client to complete school work is aligned with Erikson's psychosocial stage of industry vs. inferiority. This stage emphasizes the importance of developing competence and skills, including academic achievements, during the school-age years. Supporting the child's educational needs is crucial for positive psychosocial development.
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