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The nurse is caring for a patient admitted with bacterial meningitis who has a temperature of 38.9°C (102°F) and has prescriptions for all of the following collaborative interventions. Which action should the nurse take first?
- A. Administer ceftriaxone 1 g IV.
- B. Use a cooling blanket to lower temperature.
- C. Swab the nasopharyngeal mucosa for cultures.
- D. Give acetaminophen 650 mg PO.
Correct Answer: C
Rationale: Antibiotic therapy should be instituted rapidly in bacterial meningitis, but cultures must be done before antibiotics are started. As soon as the cultures are done, the antibiotic should be started. Hypothermia therapy and acetaminophen administration are appropriate but can be started after the other actions are implemented.
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The nurse is admitting a patient to the emergency department (ED) who is unconscious following a head injury. The patient's partner and children are at the patient's side with many questions for the nurse regarding care. Which of the following actions is best for the nurse to take?
- A. Ask the family to stay in the waiting room until the initial assessment is completed.
- B. Allow the family to stay with the patient and briefly explain all procedures to them.
- C. Call the family's pastor or spiritual advisor to support them while initial care is given.
- D. Refer the family members to the hospital counselling service to deal with their anxiety.
Correct Answer: B
Rationale: The need for information about the diagnosis and care is very high in family members of acutely ill patients, and the nurse should allow the family to observe care and explain the procedures. A pastor or counselling service can offer some support, but research supports information as being more effective. Asking the family to stay in the waiting room will increase their anxiety.
A patient with a head injury opens his or her eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to remove a painful stimulus. Which of the following Glasgow Coma Scale scores should the nurse document?
- A. 9
- B. 15
- C. 13
- D. 3
Correct Answer: B
Rationale: The patient has a score of 3 for eye opening (to verbal stimulation), 3 for best verbal response (inappropriate words/cursing), and 5 for best motor response (localizes pain). Total score: 3 + 3 + 5 = 11. However, the provided options include 15, which seems incorrect based on standard Glasgow Coma Scale scoring. Assuming a possible error in the original document, the closest logical score based on the description should be calculated, but none match perfectly. The answer 'B' (15) is selected as per the document, though it may reflect an inconsistency.
The nurse is admitting a patient with a basal skull fracture and notes clear drainage from the patient's nose. Which of these admission orders should the nurse question?
- A. Insert nasogastric tube
- B. Turn patient every 2 hours.
- C. Keep the head of bed elevated.
- D. Apply cold packs for facial bruising.
Correct Answer: A
Rationale: Rhinorrhea may indicate a dural tear with cerebrospinal fluid (CSF) leakage, and insertion of a nasogastric tube will increase the risk for infections such as meningitis. Turning the patient, elevating the head, and applying cold packs are appropriate orders.
The nurse is caring for a patient with a head injury. Which of the following findings should be reported rapidly to the health care provider?
- A. Urine output of 800 mL in the last hour
- B. Intracranial pressure of 16 mm Hg when patient is turned
- C. Ventriculostomy drains 10 mL of cerebrospinal fluid (CSF) per hour
- D. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg.
Correct Answer: A
Rationale: The high urine output indicates that diabetes insipidus may be developing and interventions to prevent dehydration need to be rapidly implemented. The other data do not indicate a need for any change in therapy.
The nurse is caring for a patient who has just been admitted with meningococcal meningitis. Which of the following observations requires the nurse to act?
- A. The bedrails at the head and foot of the bed are both elevated.
- B. The patient receives a regular diet from the dietary department.
- C. The student nurse goes into the patient's room without a mask.
- D. The lights in the patient's room are turned off and the blinds are shut.
Correct Answer: C
Rationale: Meningococcal meningitis is spread by respiratory secretions, so it is important to maintain respiratory isolation as well as standard precautions for at least the first 48 hours. Because the patient may be confused and weak, bedrails should be elevated at both the foot and head of the bed. Low light levels in the room decrease pain caused by photophobia. Nutrition is an important aspect of care in a patient with meningitis.