A client has been placed on Contact Precautions. The client’s family is very afraid to visit. What is the best action for the nurse to take?
Demonstrate to the family how to avoid spreading the disease.
Reassure the family that they will not get the infection.
Encourage the family that it is important that they visit the client.
Inform them that these precautions are mandated by law.
The Correct Answer is A
Choice A rationale:
Addresses the family's fear directly: By demonstrating how to avoid spreading the disease, the nurse directly addresses the family's primary concern, which is the fear of contracting the infection. This proactive approach provides education and reassurance, empowering the family to make informed decisions about visitation.
Promotes understanding and adherence to precautions: Clear instruction on how to don and doff personal protective equipment, hand hygiene techniques, and other infection control measures increases the likelihood that the family will follow the precautions correctly, reducing the risk of transmission.
Empowers the family to make informed choices: By providing knowledge and skills, the nurse enables the family to feel more confident in their ability to visit safely. This sense of control can help to alleviate anxiety and promote positive coping mechanisms.
Facilitates open communication and trust: The demonstration creates an opportunity for the nurse to answer questions, address concerns, and build rapport with the family. This open dialogue can foster trust and collaboration, which are essential for effective care.
Choice B rationale:
May provide false reassurance: While it's important to offer support and hope, it's not always possible to guarantee that family members will not contract the infection. Absolute reassurances could potentially lead to complacency or disregard for precautions, increasing the risk of transmission.
Fails to address the need for education: Simply stating that the family won't get sick doesn't provide them with the knowledge and skills needed to protect themselves and the client. This lack of understanding could result in accidental transmission.
Choice C rationale:
May pressure the family: Encouraging visitation without addressing underlying fears and concerns could be perceived as pressure, leading to resentment, anxiety, or even avoidance. It's important to respect the family's decision-making process and provide support regardless of their choice.
Doesn't prioritize safety: While emotional support is important, the primary focus should be on ensuring the safety of both the client and the family. Encouraging visitation without proper education and precautions could compromise safety.
Choice D rationale:
Focuses on compliance rather than understanding: Informing the family about legal mandates may come across as authoritarian and could potentially increase anxiety or resistance. It's more effective to focus on the rationale behind the precautions and emphasize their role in protecting both the client and the family.
Misses an opportunity to build trust: Simply stating the rules without engaging in dialogue may hinder open communication and trust-building. Taking a collaborative approach and addressing concerns can lead to better understanding and adherence to precautions.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale:
It is not accurate to state that the patient is at risk for seizures due to fungal infections. While fungal infections can occur in individuals with HIV-1, they are not a primary cause of seizures in this population.
Linking fungal infections directly to seizure risk without clear evidence could cause unnecessary anxiety in the patient. It's important to provide accurate and relevant information to patients.
Choice B rationale:
Responding with "I have no idea why you would be taking this drug" is unprofessional and unhelpful.
Nurses are expected to have a basic understanding of the medications their patients are taking and to be able to provide education and support.
It's essential to demonstrate knowledge and confidence when interacting with patients.
Choice C rationale:
While gabapentin can have mood-elevating effects in some individuals, it is not primarily used as an antidepressant. Mentioning this potential side effect without clarifying the primary purpose of the medication could mislead the patient. It's crucial to prioritize the main indication for the medication to avoid confusion.
Choice D rationale:
This is the most appropriate response because it accurately explains the primary reason for prescribing gabapentin to this patient.
Gabapentin is commonly used to treat neuropathic pain, which is pain caused by nerve damage.
HIV-1 can often lead to neuropathic pain, making gabapentin a valuable treatment option in this population.
Providing clear and accurate information about medication purpose builds trust and understanding between the nurse and the patient.
Correct Answer is B
Explanation
Choice A rationale:
Hourly neurologic checks are not the priority intervention for a client with hypokalemia. While hypokalemia can cause neuromuscular changes, such as muscle weakness and cramps, these are not typically the most immediate or life-threatening concerns.
Cardiac monitoring is crucial to detect and manage potentially fatal arrhythmias promptly.
Neurologic checks can be implemented as part of the overall assessment and monitoring plan, but they should not supersede cardiac monitoring in this situation.
Choice C rationale:
Seizure precautions are not routinely initiated for clients with hypokalemia unless there is a specific seizure history or other neurological concerns.
Hypokalemia can cause neuromuscular irritability, but it does not directly trigger seizures in most cases. The priority remains cardiac monitoring due to the significant risk of arrhythmias.
Choice D rationale:
Administering oxygen via face mask might be considered if the client exhibits respiratory distress or hypoxemia. However, it's not the immediate priority intervention for hypokalemia without accompanying respiratory compromise.
Hypokalemia primarily affects cardiac conduction, necessitating prompt cardiac monitoring.
Oxygen therapy can be administered if clinically indicated, but it does not address the underlying electrolyte imbalance.
Rationale for the correct answer, B:
Initiating cardiac monitoring is the most crucial nursing action for a client with a serum potassium level of 2.8 mEq/L. Here's a detailed explanation:
Hypokalemia's significant cardiac effects:
Potassium is essential for normal cardiac conduction and muscle contraction. Hypokalemia disrupts the electrical activity of the heart, potentially leading to:
Arrhythmias (irregular heartbeats), including potentially fatal ones like ventricular tachycardia or fibrillation. Electrocardiogram (ECG) changes, such as ST segment depression, T wave flattening or inversion, and prominent U waves. Cardiac monitoring's role:
Continuously tracks the heart's electrical activity. Enables early detection of arrhythmias.
Facilitates prompt intervention to prevent life-threatening complications. Specific benefits of cardiac monitoring in hypokalemia:
Allows for early identification and treatment of arrhythmias, potentially preventing cardiac arrest. Guides electrolyte replacement therapy, ensuring appropriate potassium administration.
Assesses the effectiveness of interventions, ensuring the patient's stability.
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