Page 1129 - Saunders Comprehensive Review For NCLEX-RN

Reference: McKinney et al. (2018), pp. 1301-1302.

390. Answer: 4

Rationale: Meningitis is an infectious process of the central nervous system
caused by bacteria and viruses; it may be acquired as a primary disease or as a result
of complications of neurosurgery, trauma, infection of the sinus or ears, or systemic
infections. A major priority of nursing care for a child suspected to have meningitis
is to administer the prescribed antibiotic as soon as a culture is obtained. The child
also is placed on respiratory isolation precautions for at least 24 hours while culture
results are obtained and the antibiotic is having an effect. Enteric precautions and
neutropenic precautions are not associated with the mode of transmission of
meningitis. Enteric precautions are instituted when the mode of transmission is
through the gastrointestinal tract. Neutropenic precautions are instituted when a
child has a low neutrophil count.
Test-Taking Strategy: Focus on the subject, the mode of transmission of
meningitis. Eliminate options 1 and 2 first because they are comparable or alike, and
are unrelated to the mode of transmission. Recalling that it takes about 24 hours for
antibiotics to reach a therapeutic blood level will assist in directing you to the correct
option.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process—Planning
Content Area: Pediatrics: Neurological
Health Problem: Pediatric-Specific: Meningitis
Priority Concepts: Infection; Safety
Reference: McKinney et al. (2018), pp. 1302-1303.

391. Answer: 2

Rationale: Hydrocephalus occurs as a result of an imbalance of cerebrospinal fluid
absorption or production that is caused by malformations, tumors, hemorrhage,
infections, or trauma. It results in head enlargement and increased intracranial
pressure (ICP). In infants with hydrocephalus, the head grows at an abnormal rate,
and if the infant is not repositioned frequently, pressure ulcers can occur on the back
and side of the head. An egg crate mattress under the head is also a nursing
intervention that can help prevent skin breakdown. Proteinuria is not specific to
hydrocephalus. Stimulus should be kept at a minimum because of the increase in
ICP. It is not necessary to check the blood pressure every 15 minutes.
Test-Taking Strategy: Note the strategic word, priority. Focus on the child’s
diagnosis. Eliminate option 4 because of the words 15 minutes. From the remaining
options, recall that because of the severe head enlargement, the nursing intervention
that has priority is to reposition the infant frequently to prevent the development of
pressure areas.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation

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