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Home Q & A Board Biology-Related Homework Help Medicine Nursing and Clinical
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mushtaqa1@yahoo mushtaqa1@yahoo
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6 years ago
A 23-month-old child is admitted to the hospital with a diagnosis of meningitis. She is lethargic and very irritable with a temperature of 102 F. What should the nurse's care plan include?
 
  a. Observing the child's voluntary movement
  b. Checking the Babinski reflex every 4 hours
  c. Checking the Brudzinski reflex every 1 hour
  d. Assessing the level of consciousness (LOC) and vital signs every 2 hours
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6 years ago
ANS: D
Observation of vital signs, neurologic signs, LOC, urinary output, and other pertinent data is carried out at frequent intervals on a child with meningitis. The nurse should avoid actions that cause pain or increase discomfort, such as lifting the child's head, so the Brudzinski reflex should not be checked hourly. Checking the Babinski reflex or child's voluntary movements will not help with assessing the child's status.
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