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 C
Explanation
Choice A rationale
Blood pressure is not the most reliable indicator of fluid loss in infants. Blood pressure can remain normal until dehydration is severe.
Choice B rationale
Respiratory rate can be affected by many factors and is not the most reliable indicator of fluid loss.
Choice C rationale
Body weight is the most reliable indicator of fluid loss in infants. A significant decrease in body weight indicates significant fluid loss and helps guide appropriate fluid replacement therapy.
Choice D rationale
Skin integrity can be affected by many factors and is not the most reliable indicator of fluid loss.
Correct Answer is C
Explanation
Choice A rationale
While discipline is an important aspect of parenting, the nurse’s response should focus on normalizing the child’s behavior and providing reassurance to the parent. Discussing discipline methods may not address the parent’s immediate concern about temper tantrums.
Choice B rationale
Suggesting that some children have more difficult personalities and recommending parenting books may not provide the immediate reassurance and understanding the parent needs. It is important to normalize the child’s behavior and explain that temper tantrums are a normal part of development.
Choice C rationale
Toddlers are beginning to develop a sense of autonomy and independence, which can lead to temper tantrums as they assert their desires and preferences. Explaining that temper tantrums are normal during this stage of development helps reassure the parent and provides a better understanding of their child’s behavior.
Choice D rationale
While diet can play a role in behavior, the nurse’s response should focus on normalizing the child’s behavior and providing reassurance. Discussing diet may not address the parent’s immediate concern about temper tantrums and difficult behaviors.