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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is B
Explanation
Choice A: A negative-pressure isolation room
A negative-pressure isolation room is typically used for patients with airborne infections, such as tuberculosis or measles, to prevent the spread of infectious agents through the air. Scabies, however, is primarily transmitted through direct skin-to-skin contact and occasionally through contact with contaminated clothing or bedding. Therefore, a negative-pressure isolation room is not necessary for a scabies patient1.
Choice B: A private room
A private room is the most appropriate choice for a client with scabies. This type of room helps prevent the spread of the infestation to other patients and allows for better control of the environment. Scabies is highly contagious and can spread through direct contact with the infested person or indirectly through contaminated items. Isolating the patient in a private room minimizes the risk of transmission and allows for proper infection control measures to be implemented2.
Choice C: A semi-private room with a client who has pediculosis capitis
Placing a scabies patient in a semi-private room with another patient, even one with a different parasitic infection like pediculosis capitis (head lice), is not advisable. Both conditions are highly contagious, and cohabitation increases the risk of cross-contamination and further spread of both infestations. Each condition requires specific treatment and isolation protocols to effectively manage and prevent outbreaks3.
Choice D: A positive-pressure isolation room
A positive-pressure isolation room is designed to protect immunocompromised patients from external contaminants by ensuring that air flows out of the room rather than in. This type of room is not suitable for a scabies patient, as it does not address the primary mode of transmission for scabies, which is direct contact. The focus for scabies management should be on preventing direct and indirect contact with others4.
Correct Answer is B
Explanation
Choice A reason:
“It is a test that determines which activities you feel most comfortable performing” is not entirely accurate. While comfort with activities may be assessed, the primary goal of a functional assessment is to evaluate the client’s ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs).
Choice B reason:
“It is a tool that is used to determine your maximum level of self-sufficiency.” This response accurately reflects the purpose of a functional assessment. The assessment evaluates the client’s ability to perform ADLs and IADLs independently, which helps determine the level of assistance they may need.
Choice C reason:
“It is a tool that is used to assess what services you will need a home health aide to perform for you” is partially correct but not comprehensive. While the assessment can help identify the need for home health aide services, its primary purpose is to evaluate overall self-sufficiency and functional status.
Choice D reason:
“It is a tool used by insurance companies to determine qualifications for medical reimbursement” is not the primary purpose of a functional assessment. Although the results may be used for insurance purposes, the main goal is to assess the client’s functional abilities and needs.