A client presents to the emergency department with muscle aches, headache, fever, and describes a recent loss of taste and smell.
The nurse obtains a nasal swab for COVID-19 testing. Which action is most important for the nurse to take?
Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus.
Isolate the client from other clients, family, and healthcare workers not wearing proper personal protective equipment (PPE).
Report the COVID-19 result to the local health department according to Center for Disease Control (CDC) guidelines.
Counsel family members to monitor for illness symptoms for 2 weeks after last contact with patient.
The Correct Answer is B
Choice A rationale:
While teaching the client about infection prevention measures is important, it is not the most immediate priority in this situation. The client is already potentially contagious, and these measures may not be sufficient to prevent transmission if the client is not properly isolated.
It's crucial to remember that the client may be experiencing cognitive impairment due to illness, making it harder to fully comprehend and adhere to instructions.
Additionally, some clients may not have access to or be able to afford masks and hand sanitizer, potentially hindering compliance with these measures.
Choice B rationale:
Isolating the client is the most critical action to prevent the spread of COVID-19 to others. This includes separating the client from other patients, family members, and healthcare workers who are not wearing proper PPE.
PPE, such as gloves, gowns, masks, and eye protection, creates a barrier between the healthcare worker and the client, minimizing the risk of transmission via direct contact or droplets.
Proper isolation techniques include placing the client in a designated negative-pressure isolation room, if available, or designating a separate area within a multi-bed room.
It's essential to restrict the client's movement within the healthcare facility and limit visitors to essential personnel only.
Choice C rationale:
Reporting the COVID-19 result to the local health department is important for tracking and managing the spread of the virus; however, it is not the most immediate priority in this situation.
The priority is to prevent further transmission by isolating the client.
Choice D rationale:
Counseling family members to monitor for symptoms is important, but it is not the most immediate priority in this situation. The priority is to prevent transmission by isolating the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Anorexia is a common symptom of cirrhosis, but it is not the most immediate concern in a client with esophageal varices.
Anorexia can result from various factors, including impaired liver function, hormonal imbalances, early satiety due to ascites,
and nausea.
While it's important to address anorexia to maintain nutritional status, it doesn't directly indicate a life-threatening
complication like bleeding varices.
Choice B rationale:
Brown, foamy urine is a characteristic of kidney problems, specifically proteinuria.
It's not directly associated with esophageal varices or their complications.
While cirrhosis can affect kidney function due to fluid imbalances and impaired filtering, brown, foamy urine wouldn't be the
primary indicator of bleeding varices.
Choice C rationale:
Clay-colored stool is a sign of biliary obstruction, which can occur in cirrhosis due to impaired bile flow.
However, it's not a direct indicator of bleeding varices.
Clay-colored stool results from a lack of bile pigments in the stool, which give it its typical brown color.
Choice D rationale:
Hematemesis, or vomiting of blood, is the most critical symptom to monitor in a client with esophageal varices.
Here's why:
Esophageal varices are enlarged, swollen veins in the esophagus that develop due to increased pressure in the portal venous
system, a common consequence of cirrhosis.
These varices are fragile and prone to rupture, which can lead to massive, life-threatening bleeding.
Hematemesis is a clear sign that variceal bleeding has occurred and requires immediate intervention.
Correct Answer is B
Explanation
A Colloidal oatmeal-based lotion: Colloidal oatmeal can help to reduce itching and swelling, all while hydrating the skin. It is often used to soothe irritated skin and can be incorporated into a skincare routine through oatmeal baths or oatmeal-infused moisturizers. However, it is typically used as a complementary treatment and may not be sufficient to manage psoriasis symptoms on its own.
B Topical corticosteroids: These are an essential tool for treating inflammatory skin conditions such as psoriasis34. They work by reducing inflammation and slowing down the production of skin cells, which helps to alleviate symptoms such as redness, itching, and scaling. Topical corticosteroids are often the first line of treatment for mild to moderate psoriasis.
C. Topical analgesics: These are primarily used to relieve pain. While they may provide some relief from discomfort associated with psoriasis, they do not address the underlying inflammation and rapid skin cell production that characterize this condition.
D Topical antifungal: Antifungal agents are typically used to treat conditions like seborrheic dermatitis and scalp psoriasis, or in areas where psoriasis involves folds in the skin, where there is an increased potential for localized infection. However, they are not typically used as a primary treatment for psoriasis.
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