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 ["A","B","C"]
Explanation
Choice A reason:
Conflict resolution skills are essential for effective nurse leadership. Leaders must be able to manage and resolve conflicts within the team to maintain a positive and productive work environment. Effective conflict resolution promotes teamwork and improves patient care.
Choice B reason:
Integrity is a fundamental quality of an effective nurse leader. Leaders with integrity are honest, ethical, and trustworthy. They set a positive example for their team and build a culture of trust and respect.
Choice C reason:
The ability to set priorities is crucial for nurse leaders. Effective leaders can identify the most important tasks and allocate resources appropriately. This skill ensures that the team focuses on activities that have the greatest impact on patient care and outcomes.
Choice D reason:
An authoritarian leadership style is not characteristic of effective nurse leadership. This style can lead to a lack of collaboration and low team morale. Effective nurse leaders typically use a more collaborative and inclusive approach to leadership.
Choice E reason:
Being resistant to change is not a quality of an effective nurse leader. Healthcare is a dynamic field that requires adaptability and openness to new ideas and practices. Effective leaders embrace change and guide their teams through transitions to improve care and outcomes.
Correct Answer is B
Explanation
Choice A reason:
The assistive personnel’s ability to complete the task without assistance is important, but it is encompassed within the broader consideration of their competency and experience. Ensuring that the personnel can perform the task independently is part of assessing their overall capability.
Choice B reason:
The assistive personnel’s level of experience and competency in performing the task is a critical factor in the delegation process. The nurse must ensure that the personnel have the necessary skills and knowledge to perform the task safely and effectively. This consideration aligns with the “right person” aspect of the five rights of delegation, ensuring that the task is delegated to someone who is qualified to perform it.
Choice C reason:
The assistive personnel’s rapport with clients is beneficial for providing compassionate care, but it is not a primary consideration in the delegation process. The focus should be on the personnel’s ability to perform the task competently and safely.
Choice D reason:
The assistive personnel’s availability at the time of the delegation is a logistical consideration, but it does not address the critical aspect of competency. While availability is necessary, it is secondary to ensuring that the personnel are capable of performing the task.