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","E"]
Explanation
Choice A reason:
Assigning the client to a private room is not the priority action in this scenario. The focus should be on decontamination and preventing the spread of the unknown substance to others in the emergency department. Isolation measures can be considered after initial decontamination.
Choice B reason:
Removing the client and transport crew from the Emergency department is a priority action to prevent contamination of the area and exposure to other patients and staff. This step helps contain the potential hazard and ensures the safety of everyone in the department.
Choice C reason:
Contacting the decontamination team is essential for managing the situation. The decontamination team has the expertise and equipment to safely remove the unknown substance from the client and transport crew, reducing the risk of further exposure and contamination.
Choice D reason:
Calling the scene to identify the chemical can be helpful, but it is not the immediate priority. The focus should be on decontamination and ensuring the safety of the client and others. Identifying the chemical can be done concurrently or after initial decontamination efforts.
Choice E reason:
Immediately removing the saturated clothing from the client is a critical step in the decontamination process. Removing contaminated clothing helps reduce the client’s exposure to the substance and prevents further absorption through the skin.
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.