Pediatrics Question #37

Question

Which intervention(s) should the nurse implement for a child who has nuchal rigidity, significant
lethargy, and a temperature of 102 F (38.9 C) due to suspected meningococcal meningitis? (Select all that apply.)

Answers

1. Maintain the client's NPO status.
   • Rationale:
2. Encourage the client to sleep prone for comfort.
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3. Enforce isolation precautions until discharge.
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4. Place the client in a negative pressure room.
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5. Maintain a calm environment as much as possible.
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Overview

Explanation

The correct answers are A and E. The child is at risk for nausea and vomiting. Diagnostic tests may need to be completed that require NPO status. A calm environment should be maintained as minimal stimulation is ideal to avoid cerebral irritation. A child with suspected meningitis would not be placed in a prone position due to the risk of vomiting, seizures, and increased intracranial pressure (ICP). Meningococcal meningitis is caused by bacteria that can be transmitted by close contact. Isolation will be a nursing intervention but is not the immediate intervention based on the other data. A negative pressure isolation room is used for airborne diseases.

Learning Outcomes

Test Taking Tip

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