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 B
Explanation
Choice A rationale
Restraining the child’s arms during a seizure is not recommended. Restraint can cause injury to the child and does not prevent the seizure from occurring. Instead, the focus should be on ensuring the child’s safety by removing any nearby objects that could cause harm.
Choice B rationale
Positioning the child laterally (on their side) is the correct action. This position helps maintain an open airway and allows any secretions to drain out of the mouth, reducing the risk of aspiration. It also facilitates better breathing and prevents the tongue from obstructing the airway.
Choice C rationale
Attempting to stop the seizure is not advisable. Seizures typically run their course and attempting to stop them can cause more harm than good. The nurse should focus on ensuring the child’s safety and monitoring the seizure’s duration and characteristics.
Choice D rationale
Using a padded tongue blade is outdated and not recommended. Inserting any object into the mouth during a seizure can cause injury to the teeth, gums, or airway. It is better to ensure the child’s safety by positioning them laterally and monitoring their airway.
Correct Answer is A
Explanation
Choice A rationale
Hirschsprung’s disease is characterized by inadequate motility of part of the intestine, resulting in a mechanical obstruction. This condition is caused by the absence of ganglion cells in the affected segment of the intestine, leading to a lack of peristalsis and subsequent obstruction.
Choice B rationale
Encopresis is a condition characterized by the repeated passage of feces into inappropriate places, such as clothing or the floor. It is not associated with inadequate motility of the intestine or mechanical obstruction.
Choice C rationale
Pyloric stenosis is a condition characterized by the narrowing of the pylorus, which leads to obstruction of the passage of food from the stomach to the small intestine. It is not associated with inadequate motility of the intestine.
Choice D rationale
Enterocolitis is an inflammation of the intestine and colon. It is not associated with inadequate motility of the intestine or mechanical obstruction.