A nurse is assessing a client who has a heart rate of 56/min.
Which of the following findings should the nurse expect?

The correct answer is Choice A, Choice B

Choice A rationale: Clostridium difficile is a spore-forming, gram-positive anaerobic bacillus that causes antibiotic-associated colitis. Transmission occurs via the fecal-oral route, primarily through contact with contaminated surfaces or hands. Protective gowns are essential during care to prevent spore transfer to clothing and subsequent environmental contamination. Spores resist alcohol-based sanitizers and persist on surfaces for months. Contact precautions, including gown use, reduce nosocomial spread. Normal white blood cell count is 4,000–11,000/mm³; elevated levels may indicate infection severity.

Choice B rationale: Isolation in a private room is critical for clients with confirmed Clostridium difficile infection due to the organism’s ability to form resilient spores that contaminate surfaces and equipment. Private rooms limit environmental exposure and reduce cross-contamination risk. C. difficile spores are resistant to routine cleaning agents and require bleach-based disinfectants. Diarrheal stool volume increases transmission risk. Normal stool frequency is 1–3 formed stools/day; 4–5 liquid stools/day indicates active infectious diarrhea requiring isolation.

Choice C rationale: N-95 respirators are designed for airborne pathogens such as Mycobacterium tuberculosis, measles virus, or varicella-zoster virus. Clostridium difficile is not airborne; it transmits via contact with contaminated surfaces or hands. Spores are shed in feces and do not aerosolize under normal conditions. Therefore, N-95 respirators offer no added protection against CDI. Airborne precautions are unnecessary unless aerosol-generating procedures are performed on patients with concurrent airborne infections. Respiratory rate normal range is 12–20 breaths/min.

Choice D rationale: Negative pressure rooms are used to contain airborne pathogens by maintaining lower air pressure inside the room, preventing contaminated air from escaping. Clostridium difficile does not spread via airborne particles but through contact with contaminated surfaces and feces. Thus, negative pressure rooms are not scientifically justified for CDI. Instead, contact isolation and environmental decontamination are prioritized. Room air exchanges are irrelevant to CDI control. Normal room air pressure is neutral unless airborne precautions are indicated.

Choice E rationale: Masking the client is a droplet precaution used for pathogens like influenza virus, Neisseria meningitidis, or SARS-CoV-2. Clostridium difficile does not transmit via respiratory droplets, so placing a mask on the client during transport does not reduce transmission risk. Instead, hand hygiene and contact precautions are essential. CDI spores are not expelled via coughing or sneezing. Droplet precautions are reserved for pathogens with particle size >5 µm. Normal oxygen saturation is ≥95% on room air.

Choice A rationale:

Health education involves providing information and knowledge to clients about their health, which is essential but doesn't directly relate to the nurse's action of blood pressure screening. This choice is less appropriate in this context.

Choice B rationale:

Health promotion encompasses actions that aim to enhance an individual's well-being and prevent illness. Blood pressure screening is a preventive measure to identify individuals at risk of hypertension, making it a key component of health promotion. The nurse is contributing to the client's overall health by identifying potential hypertension issues.

Choice C rationale:

Holistic health refers to a broader approach to healthcare that considers the physical, mental, and social aspects of an individual. While it's essential, the nurse's specific action of blood pressure screening doesn't necessarily encompass all these aspects. It's more focused on identifying a specific health condition.

Choice D rationale:

Disease prevention involves activities to prevent the occurrence or progression of diseases. Blood pressure screening falls under this category as it aims to prevent complications related to hypertension, making this choice a relevant consideration. However, "Health promotion" is a more precise and comprehensive description of the nurse's role in this scenario.