A nurse is planning care for a 6-year-old child who has bacterial meningitis. Which of the following nursing interventions is unnecessary in the client’s plan of care?
Measure head circumference every shift.
Implement seizure precautions.
Admit the client to a private room.
Place the client in a semi-Fowler’s position.
The Correct Answer is A
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.
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Correct Answer is A
Explanation
Choice A rationale
Encouraging the parents to rock the infant provides comfort and emotional support, which is crucial for the infant’s recovery. Rocking can also help soothe the infant and promote bonding between the parents and the child.
Choice B rationale
Administering ibuprofen as needed for pain is not recommended for infants under 6 months of age due to the risk of adverse effects such as gastrointestinal bleeding and kidney damage.
Choice C rationale
Positioning the infant on her abdomen is contraindicated after cleft lip repair surgery as it can put pressure on the surgical site, potentially causing damage and increasing the risk of infection.
Choice D rationale
Offering the infant a pacifier is not advisable as sucking can put strain on the surgical site, potentially leading to complications and delaying the healing process.
Correct Answer is A
Explanation
Choice A rationale
Projectile vomiting is a hallmark symptom of pyloric stenosis. It occurs due to the obstruction at the pylorus, causing forceful expulsion of stomach contents. This symptom typically appears in infants between 3 to 6 weeks of age.
Choice B rationale
A rigid abdomen is not a typical symptom of pyloric stenosis. It may indicate other abdominal issues, such as peritonitis or bowel obstruction.
Choice C rationale
Red currant jelly stools are associated with intussusception, not pyloric stenosis. Intussusception involves the telescoping of one part of the intestine into another, leading to bowel obstruction and characteristic stool appearance.
Choice D rationale
Distended neck veins are not related to pyloric stenosis. This symptom is more commonly associated with cardiac conditions or severe respiratory distress.