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:
Limiting fluid intake to prevent incontinence is not recommended as it can lead to dehydration and other complications. Proper hydration is essential for overall health, and other strategies should be used to manage incontinence.
Choice B reason:
Administration of antispasmodic medication can help manage bladder spasms and incontinence, but it is not the highest priority intervention. While medication can be part of the treatment plan, preventing skin breakdown is more critical in the immediate care of a client with reflex incontinence.
Choice C reason:
Kegel exercises to strengthen the pelvic floor can be beneficial for managing incontinence, but they may not be effective for clients with paralysis following a spinal cord injury. These exercises require voluntary muscle control, which may be impaired in such clients.
Choice D reason:
Regular perineal care to prevent skin breakdown is the highest priority intervention for a client with reflex incontinence. Incontinence can lead to skin irritation, breakdown, and infection if not managed properly. Ensuring good perineal hygiene helps prevent these complications and promotes overall skin health.