A nurse is assessing a client who reports a severe headache and stiff neck. The nurse’s assessment reveals positive Kernig’s and Brudzinski’s signs. Which of the following actions should the nurse perform first?
Decrease bright lights.
Implement droplet precautions.
Initiate IV access.
Administer antibiotics.
The Correct Answer is B
Choice A reason:
Decreasing bright lights can help alleviate discomfort for the client, especially if they are experiencing photophobia, which is common in meningitis. However, this action does not address the immediate need to prevent the spread of infection. While it is a supportive measure, it is not the first priority in managing a client with suspected meningitis.
Choice B reason:
Implementing droplet precautions is the first priority when a client presents with symptoms suggestive of meningitis, such as a severe headache, stiff neck, and positive Kernig’s and Brudzinski’s signs. Meningitis can be caused by bacterial infections that are highly contagious and spread through respiratory droplets. Initiating droplet precautions helps prevent the transmission of the infection to other clients and healthcare workers, making it the most critical initial action.
Choice C reason:
Initiating IV access is important for administering medications and fluids, but it is not the first priority. Ensuring the safety of others by implementing droplet precautions takes precedence. Once precautions are in place, the nurse can proceed with establishing IV access to facilitate further treatment.
Choice D reason:
Administering antibiotics is crucial in the treatment of bacterial meningitis, but it should be done after droplet precautions are in place to prevent the spread of infection. Prompt antibiotic therapy is essential, but the initial step must focus on infection control measures to protect others from exposure.
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View Related questions
Correct Answer is A
Explanation
Choice A reason:
The epidemiologic triangle is a model used to explain the factors that contribute to the spread of infectious diseases. It consists of three components: the agent (the cause of the disease), the host (the organism harboring the disease), and the environment (the external factors that allow the disease to spread). This model helps nurses understand how diseases are transmitted and identify strategies for prevention and control.
Choice B reason:
Levels of prevention refer to the different stages of disease prevention: primary, secondary, and tertiary. While important for understanding how to prevent and manage diseases, this approach does not specifically explain the factors that allow the reproduction and spread of infectious diseases.
Choice C reason:
The natural history of disease describes the progression of a disease from its onset to its resolution, including the stages of preclinical, clinical, and recovery or death. While this concept is important for understanding disease progression, it does not focus on the factors that contribute to the spread of infectious diseases.
Choice D reason:
Health promotion involves activities and interventions designed to improve health and prevent disease. While health promotion is crucial for overall public health, it does not specifically address the factors that allow the reproduction and spread of infectious diseases.
Correct Answer is D
Explanation
Choice A reason:
Encouraging the client to use ice therapy to alleviate muscle stiffness is not the best approach for managing multiple sclerosis (MS). While ice therapy can provide temporary relief for muscle stiffness, it does not address the need to increase venous return, prevent stiffness, or maintain muscle strength and endurance. Gentle stretching exercises are more effective for these goals.
Choice B reason:
Administering interferon is a common treatment for MS to help reduce the frequency and severity of relapses. However, it does not directly address the need to increase venous return, prevent stiffness, or maintain muscle strength and endurance. Exercise and physical therapy are more appropriate for these specific goals.
Choice C reason:
Administering corticosteroids is used to manage acute exacerbations of MS by reducing inflammation. While corticosteroids can help manage symptoms during a flare-up, they do not directly contribute to increasing venous return, preventing stiffness, or maintaining muscle strength and endurance. Regular exercise is more effective for these purposes.
Choice D reason:
Encouraging the client to perform gentle stretching exercises daily is the most appropriate action. Stretching exercises help increase venous return, prevent stiffness, and maintain muscle strength and endurance. Regular physical activity is essential for managing MS symptoms and improving overall function and quality of life.