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 D
Explanation
Choice A reason:
The client’s level of family support is important, but it is not the most critical factor in determining eligibility for Meals-on-Wheels. Family support can supplement the client’s needs, but the primary focus should be on the client’s ability to prepare meals independently.
Choice B reason:
The client’s financial resources are a consideration, but many Meals-on-Wheels programs offer services on a sliding scale or free of charge based on need. Financial resources alone do not determine eligibility; the ability to prepare meals is a more direct indicator of need.
Choice C reason:
The client’s access to transportation is relevant, especially if they need to travel to obtain food. However, Meals-on-Wheels is designed to serve homebound clients who cannot easily leave their homes, making transportation less of a concern compared to the ability to prepare meals.
Choice D reason:
The client’s ability to prepare meals is the most important factor in determining eligibility for Meals-on-Wheels. This program is specifically designed to assist individuals who are unable to prepare nutritious meals for themselves due to physical or cognitive limitations. Ensuring that clients receive adequate nutrition is the primary goal of the program.