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NurseDive Free Nursing Practice Question
A nurse in the emergency room is assessing a client who was brought in following a seizure. The nurse suspects the client may have meningococcal meningitis. Assessment findings include nuchal rigidity and a petechial rash. After Implementing droplet precautions, which of the following actions should the nurse initiate next?
A. Complete a vascular assessment.
Although meningococcal meningitis can lead to complications such as septicemia, which affects vascular status, assessing cranial nerves is more immediately pertinent. Identifying neurological deficits can provide crucial information about the extent and location of meningitis-related brain involvement.
B. Assess the cranial nerves
Meningococcal meningitis can affect the central nervous system, leading to cranial nerve involvement. Assessing the cranial nerves helps to identify any neurological deficits early, which is crucial for guiding treatment and monitoring progression.
C. Decrease environmental stimuli.
While this is important for managing a patient with meningitis to prevent further neurological irritation, it is not as immediate a priority as assessing cranial nerve function to detect any neurological impairment.
D. Administer an antipyretic.
Fever management is important, but it is not the next immediate priority after initiating droplet precautions. Assessing cranial nerves provides vital information about the patient's neurological status, which directly impacts immediate clinical decisions.
This question is an excerpt from Nurse Dive's nursing test bank - Ati med surg adult care 2 proctored exam. Take the full exam now
Full Explanation
A. Complete a vascular assessment: Although meningococcal meningitis can lead to complications such as septicemia, which affects vascular status, assessing cranial nerves is more immediately pertinent. Identifying neurological deficits can provide crucial information about the extent and location of meningitis-related brain involvement.
B. Assess the cranial nerves: This is the correct action to initiate next. Meningococcal meningitis can affect the central nervous system, leading to cranial nerve involvement. Assessing the cranial nerves helps to identify any neurological deficits early, which is crucial for guiding treatment and monitoring progression.
C. Decrease environmental stimuli: While this is important for managing a patient with meningitis to prevent further neurological irritation, it is not as immediate a priority as assessing cranial nerve function to detect any neurological impairment.
D. Administer an antipyretic: Fever management is important, but it is not the next immediate priority after initiating droplet precautions. Assessing cranial nerves provides vital information about the patient's neurological status, which directly impacts immediate clinical decisions.
Similar Questions
You are monitoring the vital signs of an 74yrold man who was admitted for a head injury after he tripped and fell at home. He takes anticoagulants for atrial fibrillation. On arrival his vital signs were stable at BP 150/86, pulse 84, respirations 14/min, but his family reported that he was more restless than usual. He lives alone after his wife passed away. 2 hours after admission, his vital
signs are now BP 166/74, pulse 54, respirations 11/min. He is now quiet and appears sleepy. He is on 2L nasal cannula and has been placed on neutropenic precautions.
Full Explanation
He is now quiet and appears sleepy. This is correct because it indicates a change in the level of consciousness, which could be a sign of increased intracranial pressure or bleeding in the brain.
A nurse is creating a plan of care for a client who has a history of tonicclonic seizure disorder. Which of the following interventions should the nurse Include? (Select all that apply.)
A. Furnish restraints at the bedside.
Furnish restraints at the bedside. This is incorrect because restraints are not recommended for clients with seizure disorder as they can increase agitation, injury, and aspiration risk. Instead, the nurse should protect the client from harm by removing any objects that could cause injury and padding the side rails if needed.
B. Elevate the side rails near the head when the client is in bed.
Elevate the side rails near the head when the client is in bed. This is correct because it can prevent the client from falling out of bed during a seizure and reduce injury risk.
C. Place the bed in the lowest position
Place the bed in the lowest position. This is correct because it can reduce injury risk if the client falls out of bed during a seizure.
D. Provide a suction setup at the bedside.
Provide a suction setup at the bedside. This is correct because it can help clear secretions and prevent aspiration after a seizure.
E. Keep an oxygen setup at the bedside.
Seizures can cause hypoxia, especially if prolonged. Having oxygen readily available ensures quick intervention to support oxygenation post-seizure.
A nurse receives a postsurgical endarterectomy client, what is the priority action for the nurse to take?
A. Ambulate 3 times a shift
Ambulate 3 times a shift: This is incorrect because ambulation is not a priority action for a postsurgical endarterectomy client. Ambulation may increase the risk of bleeding or hematoma formation at the surgical site.
B. Perform a vascular assessment
Perform a vascular assessment: This is correct because a vascular assessment is essential to monitor the patency of the graft and the perfusion of the affected extremity. The nurse should assess the pulses, color, temperature, sensation, and movement of the limb every hour for the first 24 hours and then every 4 hours thereafter.
C. Assist to the restroom
Assist to the restroom: This is incorrect because assisting to the restroom is not a priority action for a postsurgical endarterectomy client. The client may have a urinary catheter in place to prevent bladder distension and pressure on the surgical site.
D. Administer pain medications
Administer pain medications: This is incorrect because administering pain medications is not a priority action for a postsurgical endarterectomy client. Pain management is important, but it is not as urgent as assessing the vascular status of the graft and the limb.