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 C
Explanation
Choice A reason:
Developing a survey on teen pregnancies is important for understanding the prevalence and factors contributing to teen pregnancies in the community. However, it is not the most immediate priority intervention. Surveys are useful for data collection but do not provide immediate insights into the overall community health needs.
Choice B reason:
Holding a focus group to discuss immunizations is valuable for gathering community input and addressing concerns about vaccinations. While this is an important public health activity, it is more specific and does not provide a comprehensive overview of the community’s health needs.
Choice C reason:
Performing a windshield survey is a priority intervention for a public health nurse assigned to a new community. This type of survey involves systematically observing the community to gather information about its overall health status, resources, and needs. It provides a broad overview that can inform more targeted interventions and programs.
Choice D reason:
Interviewing the elderly at the senior’s center is important for understanding the specific needs of this population group. However, it is a more focused intervention and does not provide a comprehensive assessment of the entire community’s health needs.
Correct Answer is B
Explanation
Choice A reason:
Administering thrombolytics is not the first action the nurse should take. Thrombolytics are used to treat ischemic strokes, but their administration requires a thorough assessment and confirmation of the diagnosis through imaging studies. Immediate action is needed to ensure the client’s safety and initiate the stroke protocol.
Choice B reason:
Calling for help is the first action the nurse should take. The client is exhibiting signs of a possible stroke, and immediate medical intervention is required. Calling for help ensures that the stroke team or emergency response team is activated promptly to provide the necessary care.
Choice C reason:
Providing the client with water to test the gag reflex is not appropriate in this situation. The client may have difficulty swallowing, and giving water could lead to aspiration. The priority is to ensure the client’s safety and initiate the stroke protocol.
Choice D reason:
Performing carotid massage is not indicated for a client with new right-sided weakness and slurred speech. Carotid massage is used to manage certain types of arrhythmias, but it is not appropriate for suspected stroke. The focus should be on immediate assessment and intervention.