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 C
Explanation
Choice A reason:
Predicting future client outcomes based on historical data is the purpose of predictive analytics, not descriptive analytics. Predictive analytics uses statistical models and algorithms to forecast future events or behaviors. Descriptive analytics, on the other hand, focuses on summarizing and interpreting past data.
Choice B reason:
Developing new treatment protocols based on client data is more aligned with prescriptive analytics, which provides recommendations for actions based on data analysis. Descriptive analytics does not develop new protocols but rather helps in understanding and summarizing existing data.
Choice C reason:
Descriptive analytics involves summarizing and interpreting historical client data to identify trends and patterns. This type of analytics helps healthcare providers understand what has happened in the past and can inform decision-making by highlighting key insights and trends. It is a foundational step in data analysis that supports further predictive and prescriptive analytics.
Choice D reason:
Providing real-time monitoring of client’s vital signs is associated with real-time analytics or monitoring systems, not descriptive analytics. Descriptive analytics focuses on analyzing historical data rather than real-time data.
Correct Answer is A
Explanation
Choice A reason:
Hypertension is a common manifestation of increased intracranial pressure (ICP). As ICP rises, the body attempts to maintain cerebral perfusion by increasing blood pressure. This compensatory mechanism helps ensure that the brain continues to receive adequate blood flow despite the elevated pressure.
Choice B reason:
Tinnitus, or ringing in the ears, is not a typical manifestation of increased ICP. While it can be a symptom of various conditions, it is not specifically associated with elevated intracranial pressure.
Choice C reason:
Hypotension, or low blood pressure, is not a manifestation of increased ICP. In fact, the body typically responds to increased ICP with hypertension to maintain cerebral perfusion. Hypotension would be concerning for other reasons but is not indicative of elevated intracranial pressure.
Choice D reason:
Tachycardia, or an increased heart rate, is not a primary manifestation of increased ICP. While changes in heart rate can occur with severe neurological conditions, hypertension is a more direct indicator of elevated intracranial pressure.