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 ["B","C","D","E"]
Explanation
Choice A reason:
While epidemiology provides valuable data that can inform public health policies and legislation, it does not directly interpret legislation. The role of epidemiology is to gather and analyze data on health outcomes, which can then be used by policymakers to create informed legislation. Therefore, this statement does not accurately reflect the primary functions of epidemiology.
Choice B reason:
Epidemiology evaluates the effectiveness of nursing interventions by analyzing data on health outcomes before and after the implementation of specific interventions. This helps determine whether the interventions are successful in improving health and reducing disease incidence. Community health nurses rely on this data to make evidence-based decisions and improve their practice.
Choice C reason:
Epidemiology analyzes and examines the root causes of health outcomes by studying patterns, causes, and effects of health and disease conditions in populations. This analysis helps identify risk factors and underlying causes of diseases, which is essential for developing effective prevention and intervention strategies.
Choice D reason:
Epidemiology defines the burden of disease and determinants of health by quantifying the incidence, prevalence, and impact of diseases within a population. This information is crucial for public health planning and resource allocation, as it highlights the most pressing health issues and their contributing factors.
Choice E reason:
Epidemiology relates to the health status of a population by providing comprehensive data on health trends, disease outbreaks, and overall health outcomes. This information helps community health nurses understand the health needs of their populations and tailor their interventions accordingly.
Correct Answer is C
Explanation
Choice A reason:
Assisting the client with active range of motion exercises is important for preventing complications such as contractures and maintaining mobility. However, it is not the priority intervention in the acute phase of a hemorrhagic stroke. The primary focus should be on stabilizing the client and monitoring their condition closely.
Choice B reason:
Maintaining strict bed rest to minimize cerebral blood flow is not appropriate for managing a hemorrhagic stroke. While bed rest may be necessary to prevent further injury, the priority is to monitor the client’s neurological status and vital signs to detect any changes that may indicate worsening of the condition.
Choice C reason:
Monitoring vital signs and neurological status frequently is the priority intervention for a client who has experienced a hemorrhagic stroke. Close monitoring allows the nurse to detect any changes in the client’s condition promptly and take appropriate action. This is crucial for preventing complications and ensuring timely intervention if the client’s condition deteriorates.
Choice D reason:
Administering anticoagulant medications is contraindicated in hemorrhagic stroke because they can exacerbate bleeding. Anticoagulants are used in ischemic stroke to prevent clot formation, but in hemorrhagic stroke, the focus is on controlling bleeding and stabilizing the client.