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:
Restricting visitors to a few hours in the afternoon to promote client rest can help reduce fatigue, but it does not directly address the need to conserve energy throughout the day. While managing visitor times can be part of an overall strategy, it is not the most effective way to conserve energy for essential activities.
Choice B reason:
Scheduling all activities within a small block of time to allow the client a longer, uninterrupted rest period may lead to fatigue and decreased performance. Concentrating activities in a short time frame can be overwhelming and counterproductive, especially for clients with limited energy reserves.
Choice C reason:
Scheduling toilet breaks before and after any other planned activity is practical for managing personal needs but does not specifically address energy conservation. While it ensures that the client is comfortable, it does not optimize the timing of energy-intensive activities.
Choice D reason:
Scheduling energy-intensive activities at the time of day when the client has higher energy levels is the best approach to conserve energy without compromising physical or mental health. This strategy takes advantage of the client’s natural energy peaks, allowing them to perform activities more effectively and with less fatigue. It helps balance activity and rest, promoting overall well-being.
Correct Answer is ["B","C","E"]
Explanation
Choice A reason:
The central nervous system is not a common portal of entry for anthrax. Anthrax primarily enters the body through the skin, respiratory tract, or gastrointestinal tract. While it can affect the central nervous system if it spreads, it is not a primary entry point.
Choice B reason:
The integumentary system, or skin, is a common portal of entry for anthrax. Cutaneous anthrax occurs when Bacillus anthracis spores enter the body through a cut or abrasion on the skin. This form of anthrax is characterized by a localized infection that can develop into a painless ulcer with a black center.
Choice C reason:
The respiratory system is another primary portal of entry for anthrax. Inhalation anthrax occurs when spores are inhaled into the lungs. This form of anthrax is particularly dangerous and can lead to severe respiratory distress and systemic infection if not treated promptly.
Choice D reason:
The renal system is not a typical portal of entry for anthrax. While anthrax can affect multiple organ systems if it becomes systemic, it does not enter the body through the kidneys or urinary tract.
Choice E reason:
The gastrointestinal system is a potential portal of entry for anthrax. Gastrointestinal anthrax occurs when spores are ingested, typically through contaminated food or water. This form of anthrax can cause severe gastrointestinal symptoms and systemic infection.