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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Related Questions
Correct Answer is B
Explanation
A. Squamous cell carcinoma is a type of cancer and typically presents as a persistent sore or ulcer, not as a white, milky plaque.
B. Candidiasis, also known as oral thrush, can occur in immunocompromised individuals, especially those on antibiotics, immunosuppressants, and corticosteroids. The white, milky plaque that does not come off with rubbing is characteristic of candidiasis.
C. Herpes simplex can cause painful oral lesions, but it usually presents as vesicles that rupture to form ulcers.
D. Dermatitis refers to inflammation of the skin and is not typically associated with white plaques in the mouth.
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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