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
Measuring head circumference every shift is unnecessary for a 6-year-old child with bacterial meningitis. This intervention is more relevant for infants where head circumference changes can indicate increased intracranial pressure.
Choice B rationale
Implementing seizure precautions is necessary as bacterial meningitis can cause seizures due to increased intracranial pressure and inflammation.
Choice C rationale
Admitting the client to a private room is necessary to prevent the spread of infection, as bacterial meningitis can be highly contagious.
Choice D rationale
Placing the client in a semi-Fowler’s position helps reduce intracranial pressure and promotes comfort.
Correct Answer is A
Explanation
Choice A rationale
High fever is a common finding in children experiencing sickle cell crisis. The crisis is often triggered by infections, which can cause fever. The sickled red blood cells can block blood flow, leading to tissue ischemia and necrosis, which can also contribute to fever.
Choice B rationale
Bradycardia, or a slow heart rate, is not typically associated with sickle cell crisis. The crisis usually causes an increased heart rate due to pain and the body’s stress response.
Choice C rationale
Constipation is not a common finding in sickle cell crisis. The primary symptoms are related to pain and vaso-occlusion, which can cause severe pain and other complications.
Choice D rationale
Decreased respiratory rate is not a typical finding in sickle cell crisis. The crisis can cause respiratory distress due to pain and hypoxia, leading to an increased respiratory rate.