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","D","E"]
Explanation
Choice A reason:
Going automatically into the client’s bedroom without permission is inappropriate and can be seen as an invasion of privacy. The nurse should always seek consent and respect the client’s personal space. Building trust and maintaining professional boundaries are crucial in home care settings.
Choice B reason:
While it is courteous to thank the client for arranging a home visit, it is not a critical action that directly impacts the care provided. The focus should be on assessing the client’s needs and establishing a care plan.
Choice C reason:
Arranging mutual future visits is an appropriate action. It helps to establish a consistent care schedule, ensuring that the client receives ongoing support and monitoring. This is particularly important for managing chronic conditions like diabetes, where regular follow-up is essential for effective management.
Choice D reason:
Asking how the client is managing at home is a crucial part of the initial assessment. It provides the nurse with valuable information about the client’s current health status, challenges, and needs. This information is essential for developing a personalized care plan that addresses the client’s specific circumstances.
Choice E reason:
Sitting down and discussing with the client and family members is an important step in the initial home care visit. It helps to build rapport, understand the client’s support system, and involve family members in the care process. This collaborative approach ensures that everyone is informed and can contribute to the client’s care and well-being.