A nurse is assisting in the admission of a client who has measles. Which of the following isolation precautions should the nurse initiate?
Contact.
Airborne.
Protective environment.
Droplet.
The Correct Answer is B
Choice A rationale:
Contact precautions are indicated when the client has a condition that can be easily transmitted through direct contact with the client or their environment. Measles, which is an airborne disease, requires more stringent precautions due to its mode of transmission.
Choice B rationale:
The correct choice. Measles is spread through airborne particles, making airborne precautions necessary. These precautions include placing the client in a negative pressure room, wearing appropriate respiratory protection (e.g., N95 mask), and ensuring that healthcare providers are properly protected from inhaling infectious particles.
Choice C rationale:
A protective environment is a specialized form of isolation used for clients with compromised immune systems, such as those undergoing stem cell transplants. It involves maintaining a sterile environment to prevent the introduction of pathogens. This level of precautions is not applicable to clients with measles.
Choice D rationale:
Droplet precautions are appropriate for diseases that are transmitted through respiratory droplets generated by coughing, sneezing, or talking. Measles, however, is transmitted through smaller airborne particles that can remain suspended in the air for longer periods, making airborne precautions the most suitable choice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Avoiding discussions about the child's diagnosis with the sibling might create confusion and anxiety for the sibling. Open communication is essential for helping siblings understand their brother or sister's condition and cope with the changes in the family dynamic.
Choice B rationale:
Encouraging phone calls between the siblings is a positive step in promoting sibling adaptation when one of them has a chronic illness like cystic fibrosis. Maintaining connections through communication helps siblings feel involved, valued, and informed about each other's lives and challenges.
Choice C rationale:
Designating one parent to stay at home with the sibling might lead to feelings of isolation and neglect for the child with cystic fibrosis. Siblings also need support and attention during this time, and isolating one parent could hinder healthy sibling relationships.
Choice D rationale:
Avoiding having the sibling visit the child in the facility may prevent the sibling from understanding the condition and create a sense of fear or confusion. Controlled, supervised visits can actually be beneficial, as they allow the siblings to interact and support each other in a safe environment.
Correct Answer is B
Explanation
Choice A rationale:
A 15-year-old client who requests testing for a sexually transmitted infection (STI) is seeking healthcare related to sexual health, which is often considered confidential. In many jurisdictions, minors of a certain age (often 12 or older) have the legal right to consent to STI testing and treatment without parental consent. While education on sexual health and responsible decision-making is important, in this case, the nurse may not need to involve the parent if the legal requirements are met.
Choice B rationale:
This is the correct answer. Minors generally require parental consent for medical procedures, including biopsies. A biopsy involves a medical intervention that can carry risks, and it is important to have informed parental consent for procedures on underage clients.
Choice C rationale:
A 16-year-old client who requires prenatal care for pregnancy is not applicable in this scenario. Prenatal care is focused on managing the health and well-being of a pregnant individual and their developing fetus. The question does not provide information that suggests this situation.
Choice D rationale:
A 13-year-old client who requests contraception advice may have the right to access contraception services without parental consent, depending on local laws and regulations. Many places allow minors to access contraception services confidentially, recognizing the importance of sexual health and preventing unintended pregnancies. However, it's always important for healthcare providers to assess each situation and the applicable legal framework to determine whether parental involvement is required.
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