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:
“It’s not unusual to feel that way at first, but once you learn the routine, you’ll enjoy it.” While this response acknowledges the client’s feelings, it does not provide specific information about the benefits of cardiac rehabilitation. The client needs to understand how rehabilitation can help them recover and improve their quality of life.
Choice B reason:
“Diet and exercise are good for you and good for your heart.” This statement is true but too general. It does not address the client’s specific concerns about the purpose and benefits of cardiac rehabilitation. The client needs more detailed information about how the program can help them.
Choice C reason:
“Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely.” This response directly addresses the client’s concerns and provides clear information about the benefits of cardiac rehabilitation. It explains that while the damage cannot be reversed, rehabilitation can help the client regain strength, improve cardiovascular health, and safely return to their daily activities.
Choice D reason:
“Your doctor is the expert here, and I’m sure they would only recommend what is best for you.” While this statement supports the doctor’s recommendation, it does not provide the client with specific information about the benefits of cardiac rehabilitation. The client needs to understand how the program can help them personally.
Correct Answer is C
Explanation
Choice A reason:
Home care services provide medical and personal care to clients in their homes. While this option may be suitable for clients with less severe symptoms, a client with significant bilateral lower extremities muscle weakness may require more intensive rehabilitation services to improve mobility and function.
Choice B reason:
A sub-acute care facility provides care for clients who need more intensive services than those available in a traditional nursing home but do not require the full resources of a hospital. While this option may be appropriate for some clients, a rehabilitation facility is better suited for addressing the specific needs of a client with significant muscle weakness due to MS.
Choice C reason:
A rehabilitation facility is the most appropriate setting for a client with significant bilateral lower extremities muscle weakness due to MS. These facilities offer specialized programs and therapies designed to improve mobility, strength, and overall function. The client can receive comprehensive care from a multidisciplinary team, including physical therapists, occupational therapists, and neurologists.
Choice D reason:
A skilled nursing facility provides long-term care for clients with chronic conditions or disabilities. While these facilities offer medical care and assistance with daily activities, they may not provide the intensive rehabilitation services needed for a client with significant muscle weakness due to MS.