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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Correct Answer is D
Explanation
Choice A reason:
Placing the client on a low-protein, low-calorie diet is not appropriate for managing bradykinesia in Parkinson’s disease. While dietary adjustments may be necessary for overall health, they do not directly address the motor symptoms of Parkinson’s. In fact, protein intake needs to be managed carefully to avoid interference with medication absorption, but a low-calorie diet is not typically recommended.
Choice B reason:
Teaching the client to walk more quickly when ambulating is not advisable for someone with bradykinesia. Parkinson’s disease often causes difficulty with movement initiation and control, and encouraging faster walking could increase the risk of falls. Instead, strategies to improve gait and balance, such as physical therapy, are more appropriate.
Choice C reason:
Completing passive range-of-motion exercises daily can be beneficial for maintaining joint flexibility and preventing stiffness. However, this action alone does not specifically address bradykinesia, which is characterized by slowness of movement. Active exercises and physical therapy are more effective in managing bradykinesia.
Choice D reason:
Giving the patient extra time to perform activities is crucial for managing bradykinesia. Clients with Parkinson’s disease often need more time to complete tasks due to the slowness of movement. Allowing extra time helps reduce frustration and promotes independence, making it an essential part of care.
Correct Answer is B
Explanation
Choice a reason:
A negative-pressure isolation room is designed to prevent the spread of airborne infectious diseases by ensuring that air flows into the room but not out of it. This type of room is typically used for patients with diseases such as tuberculosis, measles, or COVID-19, which are spread through airborne particles. Scabies, however, is spread through direct skin-to-skin contact or by sharing personal items like bedding or clothing. Therefore, a negative-pressure isolation room is not necessary for a patient with scabies, as the primary mode of transmission is not airborne.
Choice b reason:
A private room is the most appropriate setting for a client with scabies. Scabies is highly contagious and can spread through direct skin-to-skin contact or by sharing personal items. Placing the client in a private room helps to prevent the spread of the mites to other patients and staff. In a private room, the client can be isolated effectively, and healthcare workers can implement contact precautions, such as wearing gloves and gowns, to minimize the risk of transmission. This approach ensures that the client receives appropriate care while protecting others from potential exposure.
Choice c reason:
A semi-private room with a client who has pediculosis capitis (head lice) is not suitable for a client with scabies. Although both conditions involve infestations, they are caused by different parasites and have different modes of transmission. Pediculosis capitis is spread through direct contact with infested hair or personal items, while scabies is spread through prolonged skin-to-skin contact. Placing a client with scabies in a semi-private room with another infested patient increases the risk of cross-contamination and further spread of both conditions. Therefore, this option is not recommended.
Choice d reason:
A positive-pressure isolation room is designed to protect immunocompromised patients from airborne pathogens by ensuring that air flows out of the room but not into it. This type of room is used for patients who need to be protected from infections, such as those undergoing chemotherapy or with severe immune deficiencies. Since scabies is not an airborne disease and does not pose a risk to immunocompromised patients in this manner, a positive-pressure isolation room is not appropriate for a client with scabies. The primary concern with scabies is preventing direct contact transmission, which is best managed in a private room.