A nurse is caring for a patient with suspected bacterial meningitis. Which nursing action should be the highest priority?
A 22-year-old college student presents to the emergency department with a severe headache, neck stiffness, photophobia, and a petechial rash on the trunk and extremities. The patient reports feeling ill for the past 12 hours with rapidly worsening symptoms.
1Implement droplet precautions immediately✓ 정답
2Administer prescribed analgesics for headache relief
3Prepare the patient for lumbar puncture
4Monitor vital signs every 15 minutes
해설
Droplet precautions are the highest priority to prevent transmission of bacterial meningitis, which is highly contagious via respiratory droplets. Other interventions like pain management or monitoring are secondary to safety.
Core Nursing ExplanationKey Concept Analysis: This question tests the application of Infection Control Priorities in a suspected case of Bacterial Meningitis. The core principle is that in nursing, the safety of the patient, healthcare workers, and other patients is paramount. Bacterial meningitis, caused by organisms like Neisseria meningitidis or Streptococcus pneumoniae, is a life-threatening infection of the meninges (the protective membranes covering the brain and spinal cord). It is transmitted through respiratory droplets (e.g., from coughing, sneezing, close contact). The classic triad of symptoms includes fever, headache, and nuchal rigidity (neck stiffness). The presence of a petechial rash is highly suggestive of meningococcal meningitis, which can progress rapidly to septic shock and death.
Answer Rationale: Key Point! The highest priority action is to Implement droplet precautions immediately. This aligns with the nursing process and public health principles: First, prevent harm and contain the threat. Isolating the patient stops the chain of infection, protecting other vulnerable patients in the ED and the healthcare team. This action must be taken before any diagnostic or comfort measures. The Centers for Disease Control and Prevention (CDC) guidelines mandate droplet precautions for suspected or confirmed bacterial meningitis until 24 hours after effective antibiotic therapy has been initiated.
Distractor Analysis:
② Administer prescribed analgesics for headache relief: While managing pain is an important comfort measure, it is not the priority in an acute, potentially fatal, and highly contagious situation. Symptom management comes after ensuring safety and initiating definitive treatment (antibiotics).
③ Prepare the patient for lumbar puncture: A Lumbar puncture (LP) is the definitive diagnostic test for meningitis to analyze cerebrospinal fluid (CSF). However, preparing for this procedure is not the first action. The nurse must first secure the environment to prevent disease transmission. Furthermore, antibiotics should not be delayed for the LP if it cannot be performed immediately.
④ Monitor vital signs every 15 minutes: Close monitoring is crucial for detecting complications like increased intracranial pressure (ICP) or septic shock. However, this intensive monitoring typically occurs after the patient is placed in an appropriate isolation room. Initiating precautions is the immediate step that enables safe monitoring.
Related Concepts: This scenario integrates Transmission-Based Precautions (droplet, contact, airborne), the pathophysiology of meningitis, Emergency Nursing Priorities, and the Chain of Infection. Remember the sequence: Safety/Infection Control → Assessment/Diagnostics → Intervention/Treatment → Evaluation/Comfort.
Required for pathogens spread by large droplets (>5 microns) within ~3 feet. Use a private room or cohort, and wear a surgical mask upon entry. Patient wears mask during transport.
Nursing Priorities (ABCs)
In infectious emergencies, "C" for Containment can be a critical first step before Airway, Breathing, Circulation to protect public health.
Lumbar Puncture (LP)
Diagnostic gold standard. Nursing care: position (lateral recumbent), monitor for complications (headache, herniation). Key Point! Do NOT delay antibiotics for LP if delay is anticipated.
Side-by-Side Comparison!
Transmission-Based Precautions
Pathogens/Diseases
Key Interventions
Droplet
Influenza, Pertussis, Bacterial Meningitis, Mumps
Private room. Surgical mask for staff/visitors within 3 ft. Mask on patient during transport.
Negative pressure room. N95 respirator or PAPR for staff. Patient wears surgical mask if possible.
Contact
MRSA, VRE, C. diff, RSV, Draining wounds
Private room. Gloves & gown for contact with patient/environment. Dedicated equipment.
Anatomy, Physiology & Pharmacology Points
Meninges: Three layers (Dura mater, Arachnoid mater, Pia mater) surrounding the brain and spinal cord. Inflammation here causes the classic symptoms.
Pathophysiology: Bacteria enter CSF → inflammatory response → increased WBCs, protein in CSF; increased ICP → headache, vomiting, potential herniation.
Pharmacology: Empiric antibiotic therapy (e.g., Ceftriaxone + Vancomycin) is started immediately, often before CSF culture results. Dexamethasone may be given before or with antibiotics to reduce inflammation and neurological sequelae.
Memory Tips
Meningitis Symptoms: Remember the mnemonic "MENINGITIS" – Malaise, Eye pain (photophobia), Nuchal rigidity, Intense headache, Nausea/vomiting, Glasgow Coma Scale (GCS) decrease, Increased temperature, Trouble with rash (petechial), Irritability, Seizures.
Priority Order: Think "Stop the Spread, Then Save the Head". Infection control first, then neurological/hemodynamic management.
High-Frequency NCLEX Topics
NCLEX heavily tests infection control and safety. You must know which precaution is required for which disease. Bacterial meningitis is a classic "priority-setting" question where the correct answer is often the infection control measure, not the diagnostic test or comfort care. Expect questions on signs of increased ICP, LP nursing care, and medication administration (timing of antibiotics vs. steroids).
Watch Out for Question Variations!
Shift from Symptom to Intervention: "The nurse notes a petechial rash on a patient with fever and headache. Which action should the nurse take first?" (Answer: Place on droplet precautions).
Shift to Medication Priority: "Which medication should the nurse prepare to administer first?" (Answer: The prescribed antibiotic, often Ceftriaxone).
Shift to Diagnostic Procedure: "The provider orders a lumbar puncture. Which client position should the nurse assist the patient into?" (Answer: Lateral recumbent with knees flexed to chin).
Nursing Clinical Practice GuideClinical Scenario: You are the triage nurse in a busy university hospital ED. A 22-year-old student is brought in by friends. He is febrile (102.5°F/39.2°C), holding his head, and complaining the lights are too bright. You see a purplish, non-blanching rash on his chest and arms. He is alert but irritable.
Nursing Intervention Strategy:
Immediate Action (Within Minutes):
Don PPE: Put on a surgical mask yourself.
Isolate: Immediately escort the patient to a private isolation room. If none is available, move him to a segregated area and place a surgical mask on him.
Notify: Alert the charge nurse and physician of a suspected case of meningococcal meningitis. This may trigger specific hospital protocols and public health notifications.
Assessment & Monitoring (After Isolation):
Vital Signs & Neuro Checks: Perform frequent assessments: Temperature, BP, HR, RR, O2 saturation. Perform a focused neurological assessment: Level of consciousness (LOC) using Glasgow Coma Scale (GCS), pupil check, motor response.
History: Quickly obtain key history: symptom onset, recent sick contacts, vaccination history (meningococcal vaccine?), college dormitory living.
Collaborative Care:
Lab Work & LP: Assist with obtaining blood cultures before antibiotics if possible. Prepare for and assist with lumbar puncture.
Medication Administration: Administer STAT IV antibiotics and corticosteroids as ordered without delay. Ensure IV access is patent.
Comfort & Support: Dim lights, provide quiet environment, administer analgesics and antiemetics as ordered.
Patient Safety and Precautions:
Contraindications for LP: Assess for signs of significantly increased ICP (e.g., deteriorating LOC, unequal pupils, posturing). An LP in the presence of a space-occupying lesion can cause brain herniation.
Medication Cautions: IV antibiotics must be given promptly. Monitor for anaphylaxis. Be aware that killing bacteria rapidly can release endotoxins, potentially worsening symptoms initially (Jarisch-Herxheimer reaction).
Prophylaxis: Identify close contacts (household, intimate partners, dorm mates) who will need post-exposure antibiotic prophylaxis (e.g., Rifampin, Ciprofloxacin). This is a public health nursing function.
Nursing Procedure & Medication FlowProcedure: Initiating Droplet Precautions
1. Recognize the need based on symptoms/suspicion.
2. Don appropriate PPE (surgical mask, goggles if splash risk).
3. Immediately relocate patient to a private room. Door may remain open.
4. Place a "Droplet Precautions" sign on the door.
5. Instruct patient to wear a surgical mask if they must leave the room.
6. Ensure dedicated patient-care equipment is available in the room.
7. Limit patient transport and notify receiving department.
Medication: Ceftriaxone Administration
- Action: Third-generation cephalosporin; bactericidal against N. meningitidis, S. pneumoniae, H. influenzae.
- Dose/Route: Typically 2 gm IV every 12 hours.
- Nursing Considerations: Reconstitute with appropriate diluent. Administer IV over 30 minutes. Monitor for hypersensitivity. Can cause diarrhea. Do not mix with calcium-containing solutions in neonates due to risk of precipitation.
A Word from Your Senior Nurse
"In the chaos of the ED, it's easy to get drawn into the dramatic symptoms—the rash, the headache. But your first job is to be a guardian for everyone in that department. That single action of grabbing a mask and moving that student to isolation protects the elderly woman with cancer in the next bay, the newborn in the waiting room, and your own colleagues. NCLEX wants nurses who think like this: safety first, always. In practice, you'll never regret erring on the side of caution with isolation. When you see fever + stiff neck + rash, think 'Droplet Precautions NOW' and let that be your muscle memory."