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 A
Explanation
Choice A rationale:
Urticaria, commonly known as hives, is a skin rash characterized by raised, red, and itchy welts that can vary in size and shape. It is a classic manifestation of an allergic reaction. Allergic reactions can occur in response to medications like clindamycin. Urticaria is a result of histamine release and can range from mild to severe, with itching being a prominent symptom. The appearance of urticaria in a child taking clindamycin suggests a potential allergic reaction to the medication.
Choice B rationale:
Conjunctivitis, or pink eye, is inflammation of the conjunctiva, the clear membrane that covers the white part of the eye and lines the inner surface of the eyelids. While conjunctivitis can be associated with allergies, it is not a typical sign of an allergic reaction to clindamycin. Conjunctivitis is more commonly associated with eye irritation, redness, and discharge.
Choice C rationale:
A temperature of 38°C (100.4°F) alone is not a definitive sign of an allergic reaction to medication. Fever can be caused by a variety of factors, including infections, inflammatory processes, and other non-allergic reactions. While fever can be a symptom of an allergic reaction in some cases, it is not as specific as urticaria in indicating an allergic response.
Choice D rationale:
Cool extremities are not a classic sign of an allergic reaction to medication. Allergic reactions typically involve skin manifestations like hives, itching, and redness. Cool extremities might suggest poor peripheral circulation or decreased blood flow to the extremities, but they are not directly indicative of an allergic reaction to clindamycin.
Correct Answer is A
Explanation
Choice A rationale:
Adolescents are at a stage of development where body image and appearance are of significant importance. Discussing how the procedure might affect the client's appearance allows the nurse to address the adolescent's concerns and fears related to changes in their body. This can help alleviate anxiety and promote a sense of control over the situation, fostering a more positive psychological response to the surgery.
Choice B rationale:
Avoiding involving the client in decisions regarding treatment (Choice B) would not be appropriate for an adolescent. Adolescents are at a stage where they are developing autonomy and decision-making skills. Excluding them from decisions about their treatment could lead to feelings of powerlessness and hinder their sense of control.
Choice C rationale:
Emphasizing that the procedure is not a punishment (Choice C) might be suitable for younger children who might associate medical procedures with punishment. However, adolescents typically do not perceive medical procedures as punishments, so this explanation may not address their specific concerns.
Choice D rationale:
Keeping equipment out of the client's sight (Choice D) might be more relevant for younger children who might be frightened by medical equipment. Adolescents are generally better able to comprehend and cope with the presence of medical equipment. Open communication about the procedure and addressing their concerns directly would be more beneficial.
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