A 20-year-old college student presents to the emergency department with a severe headache, high fever, and neck stiffness. The patient also reports photophobia and confusion. What is the most appropriate initial nursing intervention?
Administer acetaminophen
Initiate droplet precautions
Obtain blood cultures
Perform a neurological assessment
The correct answer is to initiate droplet precautions. Meningitis is a serious infection of the meninges, often caused by bacteria or viruses. The symptoms described (severe headache, high fever, neck stiffness, photophobia, and confusion) are classic signs of meningitis. While all the options listed are important, initiating droplet precautions is crucial to prevent the potential spread of infectious agents, especially if bacterial meningitis is suspected. This protects healthcare workers and other patients from exposure.
Obtaining blood cultures is important but is typically a physician-ordered intervention. Administering acetaminophen would help with fever and pain but doesn't address the potential infectiousness. Performing a neurological assessment is necessary but not the most urgent first step in this scenario. The priority is to contain the potential spread of infection while preparing for further assessment and treatment.
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