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

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

Video Rationale