A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse’s priority?
Obtain blood cultures.
Administer an intravenous antibiotic.
Prepare the child for a lumbar puncture.
Place the child in isolation.
The Correct Answer is B
Choice A rationale
Obtaining blood cultures is important for identifying the causative organism, but it should be done immediately before or concurrently with the administration of antibiotics.
Choice B rationale
Administering an intravenous antibiotic is the priority action for a child with suspected bacterial meningitis. Early administration of antibiotics is crucial to treat the infection and prevent complications such as brain swelling and seizures.
Choice C rationale
Preparing the child for a lumbar puncture is necessary for diagnosing meningitis, but it should not delay the administration of antibiotics.
Choice D rationale
Placing the child in isolation is important to prevent the spread of infection, but it is not the immediate priority over administering antibiotics.
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Correct Answer is A
Explanation
Choice A rationale
Ignoring temper tantrums is an effective strategy for managing this behavior. By not giving attention to the tantrum, the child learns that this behavior will not achieve the desired outcome. This approach helps reduce the frequency and intensity of tantrums over time.
Choice B rationale
Restraining the child physically during a temper tantrum can escalate the situation and may cause injury to the child or the caregiver. It is not recommended as a strategy for managing temper tantrums.
Choice C rationale
Distracting the child by offering to play a game can be an effective strategy for preventing tantrums, but it is not the best approach once a tantrum has already started. Ignoring the tantrum is more effective in reducing the behavior over time.
Choice D rationale
Telling the child that temper tantrums are not acceptable may not be effective during the tantrum itself. The child is unlikely to be receptive to verbal reasoning during a tantrum. Ignoring the tantrum is a more effective strategy.
Correct Answer is D
Explanation
Choice A rationale
Asthma is a chronic respiratory condition characterized by airway inflammation and bronchoconstriction. It is not commonly associated with tetralogy of Fallot.
Choice B rationale
Polycythemia, or an increased number of red blood cells, can occur as a compensatory mechanism in response to chronic hypoxia in tetralogy of Fallot. However, it is not a primary condition associated with tetralogy of Fallot.
Choice C rationale
Pulmonary hypertension is a condition characterized by increased blood pressure in the pulmonary arteries. While it can occur secondary to congenital heart defects, it is not a primary condition associated with tetralogy of Fallot.
Choice D rationale
Tetralogy of Fallot is a congenital heart defect that includes four heart abnormalities: ventricular septal defect, pulmonary stenosis, right ventricular hypertrophy, and an overriding aorta. These defects cause altered blood flow and reduced oxygen levels in the blood.