Nursing Care for Adolescent Meningitis

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Questions and Answers

Which condition should the nurse identify as a contraindication to the procedure?

Osteoarthritis

Primary glaucoma

Hypertension

Amputation (correct)

What response should the nurse make to the son of a client with terminal cancer who reports little sleep?

I can give you information about respite care if you are interested. (correct)

It must be difficult taking care of someone who is terminally ill.

You are doing a great job taking care of your mother.

You should consider taking a sleeping pill before bed each night.

Which action should the nurse prioritize when developing a discharge plan for a client with left-sided hemiplegia?

Refer the client to a local stroke support group.

Ensure that the client has a referral for physical therapy. (correct)

Counsel caregivers about respite care options.

Consult with a case manager about insurance coverage.

What is the correct action the nurse should take when measuring the temperature of an infant?

Place the tip of the thermometer under the center of the infant’s axilla. Signup and view all the answers

Which intervention should the nurse include in the care plan for a client with bipolar disorder experiencing mania?

Encourage the client to take frequent rest periods. Signup and view all the answers

Which example should the nurse include in the teaching about malpractice issues in nursing?

Leaving a nasogastric tube clamped after administering oral medication. Signup and view all the answers

What should be the nurse's first step when preparing care for a client with bipolar disorder in a manic phase?

Encourage participation in scheduled group activities. Signup and view all the answers

What action should the nurse take immediately after discovering a missing medication in the patient’s room?

Immediately inform the physician about the missing medication. Signup and view all the answers

What precaution should the nurse initiate for a client with bacterial meningitis?

Initiate droplet precautions for the client Signup and view all the answers

Which statement indicates the client understands discharge teaching for implantable cardioverter defibrillator care?

I will wear loose clothing around my ICD Signup and view all the answers

What is an important guideline for the use of belt restraints?

Document the client’s condition every 15 minutes Signup and view all the answers

What should the nurse do next after securing the airway of a client who has overdosed on diazepam?

Administer flumazenil, the antidote for benzodiazepine overdose Signup and view all the answers

What should a nurse document after obtaining a verbal prescription for restraints on a client with acute mania?

Client’s response to restraints every 15 minutes Signup and view all the answers

When advising the adult child about living kidney donation for a father with end-stage kidney disease, what is most crucial?

Living donation carries a higher risk for the donor Signup and view all the answers

What is the recommended position for a client experiencing bacterial meningitis?

Maintain the client in a supine position Signup and view all the answers

What information regarding electronic devices should be given to a client with an ICD?

Keep your cellphone at least 6 inches away from the ICD Signup and view all the answers

Study Notes

Bacterial Meningitis Care

Initiate droplet precautions for patients with bacterial meningitis to prevent transmission.
Keep the client in a supine position to enhance comfort and maintain stability.
Perform Glasgow Coma Scale assessments at least every 24 hours to monitor neurological status.
Prophylactic acyclovir is not typically recommended for families unless specific indications are present.

Implantable Cardioverter Defibrillator (ICD) Discharge Teaching

Ensure the client wears loose clothing around the ICD to avoid irritation.
Tub baths are not recommended; clients should shower instead to keep the device dry.
Microwaves are safe to use; clients do not need to stop using them at home.
Avoid holding cellphones directly against the ICD to prevent interference.

Protocols for Belt Restraints

Remove restraints every 4 hours with a provider’s order to ensure safety and comfort.
Document the client’s condition every 15 minutes to maintain close observation.
Secure the restraints to the bed frame rail, rather than side rails, to prevent injury.
Avoid PRN restraint orders for aggressive clients unless absolutely necessary.

Acute Diazepam Overdose Management

Monitor the client's airway and secure it prior to other interventions.
Administer flumazenil, the specific antidote for benzodiazepine overdose, if indicated.
Evaluate the client for signs of suicidal behavior due to potential overdose implications.
Initiate seizure precautions due to the risk of seizures associated with overdose.

Documentation for Use of Restraints

Document the client’s condition every 15 minutes during restraint use to ensure safety and effectiveness.

Living Kidney Donation Contraindications

A history of amputations is a definitive contraindication for living kidney donation.
Osteoarthritis and hypertension can complicate donation but are not outright contraindications.
Primary glaucoma should be evaluated specifically, as its impact on donor eligibility can vary.

Supporting Family Caregivers in Hospice

Provide information on respite care options for families to help manage caregiver fatigue.
Acknowledge the emotional difficulty of caring for a terminally ill patient to validate the caregiver’s experience.
Avoid suggesting medications like sleeping pills without considering a comprehensive assessment.

Rehabilitation Facility Discharge Planning

Refer the client for physical therapy as a priority to enhance mobility post-stroke.
Consult with a case manager regarding insurance coverage to facilitate discharge.
Familiarize caregivers with respite care opportunities to support ongoing caregiver needs.
Local stroke support groups can provide additional resources and community support.

Infant Temperature Measurement

Place the thermometer tip in the center of the axilla for accurate axillary temperature measurement.
Pull the pinna of the ear forward for proper placement when measuring aural temperature.
When using the rectal route, ensure proper insertion depth, approximately 3.8 cm (1.5 in).
Consider measuring oral temperature by inserting the thermometer in front of the infant's tongue safely.

Nursing Interventions for Mania

Encourage clients experiencing mania to spend time in calm settings such as the dayroom.
Implement withdrawal of privileges for non-compliance with group therapy as a behavioral management strategy.
Recommend frequent rest periods to help in managing mania symptoms effectively.
Seclusion should be a last resort for extreme anxiety symptoms, focusing on less restrictive measures first.

Malpractice in Nursing

Examples of malpractice include improper administration of medication like potassium intravenously.
Leave of a nasogastric tube clamped is indicative of negligence, affecting patient care.
Documenting provider communication in medical records is crucial for legal protection.
Placing fall risk bracelets is a preventive measure and does not constitute malpractice.

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Description

This quiz focuses on the appropriate nursing interventions for newly admitted adolescents with bacterial meningitis. It also includes discharge teaching for clients with implantable cardioverter defibrillators. Test your knowledge on essential nursing care protocols.