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:
The assistive personnel’s ability to complete the task without assistance is important, but it is encompassed within the broader consideration of their competency and experience. Ensuring that the personnel can perform the task independently is part of assessing their overall capability.
Choice B reason:
The assistive personnel’s level of experience and competency in performing the task is a critical factor in the delegation process. The nurse must ensure that the personnel have the necessary skills and knowledge to perform the task safely and effectively. This consideration aligns with the “right person” aspect of the five rights of delegation, ensuring that the task is delegated to someone who is qualified to perform it.
Choice C reason:
The assistive personnel’s rapport with clients is beneficial for providing compassionate care, but it is not a primary consideration in the delegation process. The focus should be on the personnel’s ability to perform the task competently and safely.
Choice D reason:
The assistive personnel’s availability at the time of the delegation is a logistical consideration, but it does not address the critical aspect of competency. While availability is necessary, it is secondary to ensuring that the personnel are capable of performing the task.