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
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.
Correct Answer is D
Explanation
Choice A rationale
A diastolic murmur is not a typical finding in coarctation of the aorta. This condition is more commonly associated with systolic murmurs.
Choice B rationale
Hypotension is not a common finding in coarctation of the aorta. In fact, hypertension in the upper extremities is more typical due to the narrowing of the aorta.
Choice C rationale
Excessive crying is not a specific indicator of coarctation of the aorta. It can be a symptom of many different conditions and is not diagnostic.
Choice D rationale
Unequal upper and lower extremity pulses are a key finding in coarctation of the aorta. The narrowing of the aorta causes reduced blood flow to the lower extremities, resulting in weaker pulses compared to the upper extremities.