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 C
Explanation
Choice A reason:
Inserting a padded tongue blade into the client’s mouth is not recommended and can be dangerous. During a seizure, there is a risk of causing injury to the client’s mouth or teeth, and it can also obstruct the airway. The correct approach is to ensure the client’s safety by preventing injury, not by inserting objects into their mouth.
Choice B reason:
Restraining the client during a seizure is not advised. Restraints can cause additional harm and do not prevent the seizure from occurring. Instead, the focus should be on protecting the client from injury by ensuring a safe environment and allowing the seizure to run its course.
Choice C reason:
Moving objects away from the client is a crucial step in ensuring their safety during a seizure. This action helps prevent the client from hitting or injuring themselves on nearby objects. Creating a safe space around the client is one of the primary goals during a seizure to minimize the risk of injury.
Choice D reason:
Placing the client on their back is not recommended during a seizure. Instead, the client should be placed on their side if possible, to help keep the airway clear and reduce the risk of aspiration. This position also allows for better monitoring of the client’s breathing and overall condition.
Correct Answer is B
Explanation
Choice A reason:
Organizing an influenza immunization campaign is an example of primary prevention, which aims to prevent the onset of illness or injury before it occurs. Secondary prevention focuses on early detection and intervention to prevent the progression of disease or injury.
Choice B reason:
Helping plant workers identify signs of carpal tunnel syndrome is a secondary prevention strategy. It involves early detection of symptoms and providing education on how to manage and seek treatment for the condition. Early intervention can prevent the progression of carpal tunnel syndrome and reduce the risk of long-term complications.
Choice C reason:
Teaching plant workers about proper lifting techniques is an example of primary prevention. It aims to prevent injuries by educating workers on safe practices. While important, it does not fall under secondary prevention, which focuses on early detection and intervention.
Choice D reason:
Collaborating with a physical therapist to develop programs for injured employees to return to work is an example of tertiary prevention. Tertiary prevention focuses on rehabilitation and managing long-term health conditions to improve quality of life and prevent further complications.