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 C

Explanation

A. Gastritis is not an infectious condition and is unlikely to be the source of the child's rheumatic fever.

B. Chickenpox is caused by a different pathogen (varicella-zoster virus) and is not associated with the development of rheumatic fever.

C. Rheumatic fever often follows untreated or inadequately treated streptococcal infections, particularly streptococcal pharyngitis (sore throat). A sibling with a recent sore throat is a significant piece of information.

D. Fifth disease is caused by parvovirus B19 and is not known to be a precursor to rheumatic fever.

A. A 1-year-old toddler who has roseola and a temperature of 39° C (102.2° F) B. A 7-year-old child who has diabetes insipidus and a urine specific gravity of 1.016 C. A 10-year-old child who has sickle cell anemia who reports severe chest pain D. A 4-year-old child who has asthma and a PCO2 of 37 mm Hg

Correct Answer is C

Explanation

A. Elevated temperature in a toddler with roseola is generally self-limiting and not immediately life-threatening.

B. A urine specific gravity of 1.016 in a 7-year-old with diabetes insipidus indicates a dilute urine concentration and is not an acute priority.

C. Sickle cell anemia can lead to vaso-occlusive crises, and severe chest pain could suggest a potential life-threatening complication such as acute chest syndrome. This requires immediate attention.

D. A PCO2 level of 37 mm Hg in a 4-year-old with asthma, while indicating respiratory distress, may not be as urgently life-threatening as severe chest pain in a child with sickle cell anemia.

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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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