Nokea
Which type of precautions should the nurse implement for the client diagnosed with septic meningitis?
- A. Standard Precautions.
- B. Airborne Precautions.
- C. Contact Precautions.
- D. Droplet Precautions.
Correct Answer: D
Rationale: Meningococcal meningitis is transmitted via respiratory droplets, requiring Droplet Precautions (D) in addition to Standard Precautions. Airborne (B) and Contact (C) are not indicated.
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The client is diagnosed with a brain abscess. Which sign/symptom is the most common?
- A. Projectile vomiting.
- B. Disoriented behavior.
- C. Headaches, worse in the morning.
- D. Petit mal seizure activity.
Correct Answer: C
Rationale: Brain abscesses cause increased ICP, leading to headaches worse in the morning (C). Vomiting (A) is less specific, disorientation (B) is secondary, and petit mal seizures (D) are less common.
The client is in status epilepticus. Which interventions, if prescribed, should be included in this client's immediate treatment? Select all that apply.
- A. Administer dexamethasone intravenously.
- B. Give oxygen and prepare for endotracheal intubation.
- C. Obtain a defibrillator and prepare to use it immediately.
- D. Remove nearby objects to protect the client from injury.
- E. Administer lorazepam intravenously STAT.
Correct Answer: B,D,E
Rationale: Anticonvulsant medications such as phenytoin (Dilantin), and not anti-inflammatory medications such as dexamethasone (Decadron), are administered IV to control seizure activity. Status epilepticus is a medical emergency. The client is at risk for brain hypoxia and permanent brain damage. The client needs additional oxygen, and intubation will secure the airway. Defibrillation is treatment for ventricular fibrillation, a lethal heart dysrhythmia. Care is taken to protect the client from injury during the seizure. Either lorazepam (Ativan) or diazepam (Valium) is administered initially to terminate the seizure because they can be administered more rapidly than phenytoin.
The client is in the terminal stage of ALS. Which intervention should the nurse implement?
- A. Perform passive ROM every two (2) hours.
- B. Maintain a negative nitrogen balance.
- C. Encourage a low-protein, soft-mechanical diet.
- D. Turn the client and have him cough and deep breathe every shift.
Correct Answer: A
Rationale: In terminal ALS, passive ROM every 2 hours (A) prevents contractures and maintains comfort. Negative nitrogen balance (B) is undesirable, low-protein diets (C) are not indicated, and coughing/deep breathing (D) may be infeasible.
If the drug is administered every 3 to 4 hours, which nursing action is most appropriate at this time in response to the client's statement?
- A. Administer another dose of the nonopioid analgesic immediately.
- B. Rearrange medication times so that the client receives pain medication hourly.
- C. Consult the physician about ordering an opioid analgesic.
- D. Use a nondrug intervention such as listening to a guided imagery tape.
Correct Answer: D
Rationale: Using a nondrug intervention like guided imagery is appropriate since it's too early for another dose, and it avoids escalating to opioids prematurely.
When implementing seizure precautions, which nursing action is most appropriate?
- A. Move the client to a room closer to the nurses' station.
- B. Serve the client's food in paper and plastic containers.
- C. Maintain the client's bed in the lowest position.
- D. Ensure that soft limb restraints are applied to upper extremities.
Correct Answer: C
Rationale: Maintaining the bed in the lowest position minimizes the risk of injury from falls during a seizure.