Encephalitis

A nurse is caring for a patient with viral encephalitis. Which nursing intervention is the highest priority for this patient?

1 Administer prescribed antiviral medications as ordered
2 Monitor neurological status and implement seizure precautions ✓ 정답
3 Maintain strict isolation precautions to prevent transmission
4 Encourage increased fluid intake to prevent dehydration

해설

Monitoring neurological status and seizure precautions is the highest priority because encephalitis can rapidly cause life-threatening complications like increased ICP and seizures. Other interventions are secondary to preventing neurological deterioration.

같은 주제 다음 문제A nurse is assessing a 45-year-old patient admitted with suspected viral encephalitis. Whi…이 문제가 수록된 문제집[개념+기출] 엔클렉스(NCLEX), 이거 하나면 됩니다69,000원

Understanding the Priority: Viral Encephalitis
In managing a patient with viral encephalitis, the clinical picture is dominated by inflammation of the brain parenchyma. This inflammation can lead to increased intracranial pressure (ICP), cerebral edema, and direct neuronal irritation, which significantly lowers the seizure threshold. The provided case study highlights that this condition can mimic a large-vessel stroke, presenting with focal neurological deficits and altered consciousness ^[1]. Because the patient’s neurological status can deteriorate rapidly—progressing to malignant edema or persistent intracranial hypertension requiring life-saving interventions like decompressive craniectomy—continuous assessment is not just routine care, it is a safety imperative ^[1].

Why Seizure Precautions and Neurological Monitoring are the Priority
The highest priority intervention is monitoring neurological status and implementing seizure precautions. This is rooted in the pathophysiology of the disease and the ABC (Airway, Breathing, Circulation) framework, where neurological status is a primary component of "Disability." Seizure activity, or the postictal state following a seizure, can compromise the patient’s airway and ventilation. Furthermore, a change in the level of consciousness or the development of new focal deficits is often the earliest and most sensitive indicator of worsening cerebral edema or rising ICP. The source material emphasizes that outcomes vary and that prompt evaluation is essential when intracranial hypertension is suspected ^[1]. By establishing a baseline and trending the neurological exam, the nurse can detect these subtle but critical changes before they lead to irreversible brain herniation.

Analyzing the Other Options
While the other interventions are important components of care, they do not take precedence over the immediate safety risk of neurological deterioration.

- Administering prescribed antiviral medications (Option 1) is critical for treating the underlying cause, specifically Herpes Simplex Virus Encephalitis (HSVE), and the source notes that empiric acyclovir should be initiated urgently ^[1]. However, this is a medical treatment that addresses the etiology over hours to days. It does not immediately protect the patient from an acute seizure or a sudden rise in ICP that could occur in the next few minutes.
- Maintaining strict isolation precautions (Option 3) is a standard infection control measure. However, the most common cause of sporadic viral encephalitis, HSV-1, is not transmitted via the respiratory route but through direct contact with infected secretions. Standard precautions are typically sufficient, and this intervention does not address the immediate, life-threatening neurological risks.
- Encouraging increased fluid intake (Option 4) is generally contraindicated in the acute phase of encephalitis. Patients with cerebral edema are at risk for syndrome of inappropriate antidiuretic hormone secretion (SIADH), and fluid restriction is often part of the medical management to prevent exacerbating cerebral edema. Forcing fluids could dangerously increase ICP.

The nurse’s primary role is to ensure patient safety by identifying and mitigating the most immediate life threats. In a condition where the brain is inflamed and irritable, the risk of seizure and rapid neurological decline is the most urgent threat, making vigilant monitoring and safety precautions the top priority.

References (research sources)

[1]
A Diagnostic Challenge: From Suspected Ischemic Stroke to Confirmed Herpetic Encephalitis.Research articleNeves MD, Pereira MG, Silveira N, Barbosa S, Sousa JMM, Pereira E, Monteiro E. (2026) · DOI: 10.1002/ccr3.72772

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A nurse is caring for a patient with viral encephalitis. Which nursing intervention is the highest priority for this patient?

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