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NurseDive Free Nursing Practice Question
A nurse is admitting a child who has bacterial meningitis. Which of the following actions should the nurse take first?
A. Initiate antibiotic therapy for the child.
Initiate antibiotic therapy for the child.This is the priority action. Bacterial meningitis is a medical emergency, and prompt administration of antibiotics is crucial to treat the infection and prevent further complications. Therefore, the nurse should initiate antibiotic therapy as soon as possible after obtaining appropriate cultures.
B. Minimize the child's environmental stimuli.
Minimize the child's environmental stimuli.While reducing environmental stimuli can help decrease the child's discomfort and prevent agitation, it is not the priority action when managing bacterial meningitis. Treating the underlying infection takes precedence to prevent serious complications such as neurological damage or septic shock.
C. Place the child in a side-lying position.
Place the child in a side-lying position. Positioning the child on their side may help prevent aspiration if vomiting occurs, but it is not the priority action in the initial management of bacterial meningitis. The child's positioning can be adjusted as needed once antibiotic therapy has been initiated.
D. Administer pain medication to the child.
Administer pain medication to the child.Pain management is important for the child's comfort, but it is not the priority action when managing bacterial meningitis. The child's pain may be addressed once antibiotic therapy has been initiated and the child's condition has stabilized.
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Full Explanation
A. Initiate antibiotic therapy for the child.
This is the priority action. Bacterial meningitis is a medical emergency, and prompt administration of antibiotics is crucial to treat the infection and prevent further complications. Therefore, the nurse should initiate antibiotic therapy as soon as possible after obtaining appropriate cultures.
B. Minimize the child's environmental stimuli.
While reducing environmental stimuli can help decrease the child's discomfort and prevent agitation, it is not the priority action when managing bacterial meningitis. Treating the underlying infection takes precedence to prevent serious complications such as neurological damage or septic shock.
C. Place the child in a side-lying position.
Positioning the child on their side may help prevent aspiration if vomiting occurs, but it is not the priority action in the initial management of bacterial meningitis. The child's positioning can be adjusted as needed once antibiotic therapy has been initiated.
D. Administer pain medication to the child.
Pain management is important for the child's comfort, but it is not the priority action when managing bacterial meningitis. The child's pain may be addressed once antibiotic therapy has been initiated and the child's condition has stabilized.
Similar Questions
A nurse is caring for a 4-month-old infant who is immediately postoperative following cleft palate repair. Which of the following actions should the nurse take?
A. Give the infant liquids using a small spoon with a long handle.
Give the infant liquids using a small spoon with a long handle.While feeding is essential, the method described is not specific to postoperative care after cleft palate repair.Feedings are resumed by bottle, breast/chest, or cup per surgeon preference; some surgeons prescribe the use of an Asepto syringe for feeding or a soft cup such as a soft-tipped sippy cup.
B. Apply elbow restraints to the infant.
Apply elbow restraints to the infant is correct.Elbow restraints would be used to prevent the infant from injuring or traumatizing the surgical site.
C. Gently check the infant's suture line using a padded tongue depressor.
Gently check the infant's suture line using a padded tongue depressor. It's important to assess the surgical site for signs of infection or bleeding, but using a padded tongue depressor may not be the most appropriate method. The nurse should follow the surgeon's orders regarding wound care and assessment techniques, which may include visual inspection without manipulation.
D. Place the infant in a supine position.
Place the infant in a supine position.Placing the infant in a supine position is generally recommended after cleft palate repair surgery to minimize strain on the surgical site and promote healing. However, it's essential to ensure proper positioning to prevent aspiration and maintain airway patency.
Full Explanation
A. Give the infant liquids using a small spoon with a long handle.
Give the infant liquids using a small spoon with a long handle.While feeding is essential, the method described is not specific to postoperative care after cleft palate repair.Feedings are resumed by bottle, breast/chest, or cup per surgeon preference; some surgeons prescribe the use of an Asepto syringe for feeding or a soft cup such as a soft-tipped sippy cup.
B. Apply elbow restraints to the infant.
Apply elbow restraints to the infant is correct.Elbow restraints would be used to prevent the infant from injuring or traumatizing the surgical site.
C. Gently check the infant's suture line using a padded tongue depressor.
It's important to assess the surgical site for signs of infection or bleeding, but using a padded tongue depressor may not be the most appropriate method. The nurse should follow the surgeon's orders regarding wound care and assessment techniques, which may include visual inspection without manipulation.
D. Place the infant in a supine position.
Placing the infant in a supine position is generally recommended after cleft palate repair surgery to minimize strain on the surgical site and promote healing. However, it's essential to ensure proper positioning to prevent aspiration and maintain airway patency.
A nurse is assessing an infant who has hydrocephalus. Which of the following clinical manifestations should the nurse expect?
A. Depressed scalp veins
Depressed scalp veins: This is an incorrect choice. In hydrocephalus, there is increased pressure within the skull due to the accumulation of cerebrospinal fluid (CSF). This increased pressure typically leads to distended scalp veins rather than depressed ones.
B. Sunken anterior fontanels
Sunken anterior fontanels: This is an incorrect choice. The fontanel, also known as the soft spot on an infant's head, may actually bulge rather than appear sunken in cases of hydrocephalus due to increased intracranial pressure.
C. Bulging eyes
Bulging eyes:In individuals with hydrocephalus, especially infants and young children, bulging eyes can sometimes occur.The increased pressure inside the skull can affect various structures within the brain, including the optic nerve and the muscles that control eye movement. This can lead to a condition called papilledema, where the optic nerve becomes swollen due to the pressure. Papilledema can cause changes in vision and, in some cases, contribute to the appearance of bulging eyes.
D. Separated cranial sutures
Separated cranial sutures:The separation of cranial sutures in hydrocephalus occurs due to the increased pressure from the excess CSF. This pressure can cause the bones of the skull to move apart, leading to visible gaps or widening of the sutures. Clinically, this can be observed through imaging studies such as CT scans or MRI.
Full Explanation
A. Depressed scalp veins: This is an incorrect choice. In hydrocephalus, there is increased pressure within the skull due to the accumulation of cerebrospinal fluid (CSF). This increased pressure typically leads to distended scalp veins rather than depressed ones.
B. Sunken anterior fontanels: This is an incorrect choice. The fontanel, also known as the soft spot on an infant's head, may actually bulge rather than appear sunken in cases of hydrocephalus due to increased intracranial pressure.
C. Bulging eyes: In individuals with hydrocephalus, especially infants and young children, bulging eyes can sometimes occur. The increased pressure inside the skull can affect various structures within the brain, including the optic nerve and the muscles that control eye movement. This can lead to a condition called papilledema, where the optic nerve becomes swollen due to the pressure. Papilledema can cause changes in vision and, in some cases, contribute to the appearance of bulging eyes.
D. Separated cranial sutures: The separation of cranial sutures in hydrocephalus occurs due to the increased pressure from the excess CSF. This pressure can cause the bones of the skull to move apart, leading to visible gaps or widening of the sutures. Clinically, this can be observed through imaging studies such as CT scans or MRI.
A nurse is developing a plan of care for a 4-year-old child who has hemophilia and is experiencing acute hemarthrosis. Which of the following interventions should the nurse include in the plan?
A. Have the child perform passive range-of-motion exercises.
Have the child perform passive range-of-motion exercises: This is not recommended during acute hemarthrosis in hemophilia because it can further exacerbate bleeding and increase joint damage. Passive range-of-motion exercises should be avoided until bleeding has been adequately controlled.
B. Administer aspirin as needed for pain.
Administer aspirin as needed for pain: Aspirin is not recommended for pain management in hemophilia due to its antiplatelet effects, which can further prolong bleeding. Instead, acetaminophen (Tylenol) or other nonsteroidal anti-inflammatory drugs (NSAIDs) that do not affect clotting mechanisms may be used for pain relief.
C. Place ice packs on the affected joints.
Place ice packs on the affected joints: This is a recommended intervention. Ice packs can help reduce inflammation and swelling in the affected joints, providing pain relief and potentially slowing down bleeding. However, it's important to ensure that the ice pack is wrapped in a cloth or towel to prevent direct contact with the skin, which could cause tissue damage.
D. Position the lower extremities below the level of the heart.
Position the lower extremities below the level of the heart: This is not recommended. Elevating the affected extremity above the level of the heart can help reduce swelling and minimize bleeding. Placing the lower extremities below the level of the heart could potentially increase bleeding.
Full Explanation
A. Have the child perform passive range-of-motion exercises: This is not recommended during acute hemarthrosis in hemophilia because it can further exacerbate bleeding and increase joint damage. Passive range-of-motion exercises should be avoided until bleeding has been adequately controlled.
B. Administer aspirin as needed for pain: Aspirin is not recommended for pain management in hemophilia due to its antiplatelet effects, which can further prolong bleeding. Instead, acetaminophen (Tylenol) or other nonsteroidal anti-inflammatory drugs (NSAIDs) that do not affect clotting mechanisms may be used for pain relief.
C. Place ice packs on the affected joints: This is a recommended intervention. Ice packs can help reduce inflammation and swelling in the affected joints, providing pain relief and potentially slowing down bleeding. However, it's important to ensure that the ice pack is wrapped in a cloth or towel to prevent direct contact with the skin, which could cause tissue damage.
D. Position the lower extremities below the level of the heart: This is not recommended. Elevating the affected extremity above the level of the heart can help reduce swelling and minimize bleeding. Placing the lower extremities below the level of the heart could potentially increase bleeding.