A nurse is reviewing the prescriptions for a client who has a new diagnosis of bacterial meningitis. Which of the following prescriptions should the nurse clarify with the provider?
Place the client on droplet precautions.
Perform a cranial nerve assessment on the client every 2 hr.
Assist the client out of bed three times per day.
Assess the client's weight daily.
The Correct Answer is B
Choice A rationale:
Placing the client on droplet precautions is appropriate for bacterial meningitis, as it is spread through respiratory droplets. This measure helps prevent the spread of infection to others.
Choice B rationale:
The nurse should clarify the prescription to perform a cranial nerve assessment every 2 hours. While cranial nerve assessment is crucial in monitoring neurological status, performing it every 2 hours is excessive and not supported by evidence-based practice. Frequent assessments can be uncomfortable for the client and may not provide additional meaningful information within such a short interval.
Choice C rationale:
Assisting the client out of bed three times per day is essential for promoting mobility and preventing complications such as pressure ulcers and muscle weakness. This prescription is appropriate and does not require clarification.
Choice D rationale:
Assessing the client's weight daily is essential in monitoring fluid balance and nutritional status. There is no need to clarify this prescription, as it is a standard practice in caring for clients with bacterial meningitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Answer: A. Diplopia.
Rationale:
A) Diplopia: Diplopia, or double vision, is a common symptom in multiple sclerosis (MS) due to demyelination of nerves in the brainstem, affecting eye movement coordination. This visual disturbance is frequently seen in MS clients and may worsen during flare-ups.
B) Masklike expression: A masklike expression is more commonly associated with Parkinson’s disease rather than multiple sclerosis. This characteristic facial appearance is due to muscle rigidity, which is not typically a manifestation of MS.
C) Twitching of the face: Facial twitching, or fasciculations, is not typically a primary symptom of multiple sclerosis. While muscle weakness and spasticity are common in MS, twitching is more commonly seen in conditions such as amyotrophic lateral sclerosis (ALS).
D) Agitation: Agitation is not a primary symptom of MS. While MS can lead to cognitive changes or mood disturbances, such as depression, severe agitation is more commonly linked with other neurological or psychiatric conditions.
Correct Answer is A
Explanation
Choice A rationale:
Applying clean gloves when removing the old dressing from the catheter site is essential to prevent infection and maintain an aseptic technique during peritoneal dialysis catheter care. Gloves protect both the nurse and the patient from potential contamination.
Choice B rationale:
Cleansing the area by using a circular motion beginning at the catheter site and moving outward is not the correct technique. When caring for a dialysis catheter, the nurse should cleanse the site using an outward, circular motion starting from the insertion site to minimize the risk of contamination.
Choice C rationale:
Using warm water to cleanse the catheter site is not recommended. The peritoneal dialysis catheter site should be cleaned with an appropriate antiseptic solution or disinfectant, as warm water alone may not effectively remove bacteria or prevent infections.
Choice D rationale:
Placing an occlusive dressing over the catheter site after cleaning is not the standard practice for peritoneal dialysis catheter care. Typically, a clean, dry dressing is applied to the catheter site after cleaning to keep it clean and dry, but it should not be occlusive.
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