Question

A nurse is caring for a client who has encephalitis due to West Nile Virus. Which actions should the nurse take? SATA

A. Place the client in respiratory isolation
B. Monitor VS every 2 hours
C. Assess neuro status every 4 hours
D. Maintain the client in high fowlers
E. Keep the clients room darkened

Answer 1

For a client with encephalitis due to West Nile Virus, a nurse should monitor vital signs every 2 hours, assess neurological status every 4 hours, and keep the room darkened for comfort. Respiratory isolation is not required, and high Fowler's position is not typically necessary unless respiratory issues are present.

Step-by-step explanation:

When caring for a client with encephalitis due to West Nile Virus (WNV), it is important to follow certain precautions and supportive care measures, as there are no antiviral drugs available to treat the infection. Among the actions a nurse should take include:

• B. Monitor vital signs (VS) every 2 hours to detect any changes that might indicate worsening of the condition or other complications.
• C. Assess neurological status every 4 hours because encephalitis can cause changes in consciousness and cognition, and it is important to monitor for any signs of neurological deterioration.
• E. Keep the client's room darkened as patients with encephalitis may be sensitive to light, and a darkened room can help reduce headache and promote comfort.

Respiratory isolation is not indicated for WNV because it is not spread by respiratory secretions. Maintaining the client in high Fowler's position is specific to conditions where breathing is compromised, which is not typically the case with encephalitis.