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 ["A","B","C","E"]
Explanation
Choice A reason:
Identification of resources to meet anticipated needs is a critical component of disaster planning. Nurses play a key role in identifying the resources required for effective disaster response, including medical supplies, personnel, and equipment. This ensures that the hospital is prepared to meet the needs of patients during a disaster.
Choice B reason:
Participation in comprehensive annual drills is essential for disaster preparedness. Nurses are involved in these drills to practice and refine their response skills, ensuring they are ready to act effectively in a real disaster. Drills help identify gaps in the disaster plan and provide opportunities for improvement.
Choice C reason:
Internal and external communications are vital during a disaster. Nurses are involved in establishing and maintaining communication channels within the hospital and with external agencies. Effective communication ensures coordination and timely response, which are crucial for managing a disaster situation.
Choice D reason:
Performing duties outside the typical job description may occur during a disaster, but it is not a primary component of the disaster plan. The focus is on ensuring that all staff are prepared to perform their roles effectively. While flexibility is important, the disaster plan should primarily outline specific roles and responsibilities.
Choice E reason:
Development of a decontamination plan is an important aspect of disaster preparedness, especially in scenarios involving hazardous materials. Nurses contribute to creating and implementing decontamination protocols to protect patients and staff from exposure to harmful substances.
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.