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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale: Massaging the site with scented oils is not recommended as it may further irritate the inflamed tissue. Additionally, scented oils can cause allergic reactions or skin irritation, worsening the client's discomfort.
Choice B rationale: Applying warm compresses to the site increases blood flow, reduces inflammation, and provides pain relief. Warm compresses also promote healing by improving circulation and reducing edema, making them an appropriate intervention for phlebitis.
Choice C rationale: Administering topical lidocaine to the site is generally not recommended without a prescription. Although it may provide localized pain relief, it can mask underlying issues and delay appropriate medical assessment and treatment.
Choice D rationale: Administering prescribed oral pain medication can provide systemic pain relief. However, it may not be as effective as a localized treatment for reducing inflammation and discomfort at the site of the peripheral vascular access device.
Correct Answer is A
Explanation
Rationale for Choice A:
A shift to the left in the white blood cell (WBC) count indicates an increased presence of immature neutrophils, known as bands. This is a hallmark sign of infection, as the body is rapidly producing and releasing these cells to fight off invading pathogens.
Prompt notification of the primary health care provider is crucial to initiate timely antibiotic therapy, if indicated. Early intervention with appropriate antibiotics can effectively combat the infection, prevent its progression, and potentially avert serious complications.
Delaying antibiotic treatment can allow the infection to worsen, potentially leading to sepsis, septic shock, or other life- threatening conditions.
Rationale for Choice B:
While informing the client about the significance of a shift to the left is important for education and understanding, it does not address the immediate need for medical intervention.
The priority action is to involve the primary health care provider for prompt assessment and potential initiation of antibiotic therapy.
Rationale for Choice C:
Documenting findings and continuing to monitor the client's condition is essential for ongoing assessment and evaluation, but it does not constitute a proactive intervention to address the underlying infection.
Documentation alone does not initiate treatment, and monitoring without intervention risks allowing the infection to progress.
Rationale for Choice D:
Protective isolation is not routinely indicated for clients with a shift to the left in their WBC count unless there is a specific concern for transmission of a highly contagious infection.
The decision to implement protective isolation measures would be based on the client's overall clinical presentation and potential infectious risks, as determined by the primary health care provider.
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