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 D
Explanation
Choice A rationale
The influenza vaccine is recommended annually for all individuals, including adolescents, to protect against the flu. However, it is not specifically required for pre-college physical assessments.
Choice B rationale
The pneumococcal polysaccharide vaccine is typically administered to older adults and individuals with certain medical conditions. It is not a standard requirement for adolescents.
Choice C rationale
The Bacille Calmette-Guérin (BCG) vaccine is used in countries with a high prevalence of tuberculosis. It is not commonly administered in the United States or required for pre-college physical assessments.
Choice D rationale
The meningococcal polysaccharide vaccine is recommended for adolescents, especially those entering college, to protect against meningococcal disease, which can spread in close living quarters.
Correct Answer is D
Explanation
Choice A rationale
Explaining the difference between right and wrong is a developmental task expected of older children, typically preschoolers or early school-aged children. Toddlers are still developing their understanding of rules and consequences.
Choice B rationale
Printing letters and numbers is a skill expected of preschoolers or early school-aged children. Toddlers are still developing fine motor skills and are not yet capable of printing letters and numbers.
Choice C rationale
Cooperating in doing simple chores is a developmental task that can be expected of toddlers. However, it is not as specific or significant as the ability to separate easily from the primary caregiver for short periods of time, which is a key developmental milestone for toddlers.
Choice D rationale
Separating easily from the primary caregiver for short periods of time is an important developmental milestone for toddlers. It indicates that the child is developing a sense of independence and trust in their environment, which is crucial for their social and emotional development.